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DISEASES  OF  CHILDREN 


TAYLOR  AND   WELLS 


Extracts  from  Reviews  of  the  First  Edition 


From  "The  Brooklyn  Medical  Journal  "  : 

"  The  authors  of  this  work  modestly  disclaim  for  it  the  title  of  treatise,  but  yet 
it  covers  in  a  very  satisfactory  way  the  whole  field  embraced  in  its  subject.  The 
material  is  condensed  and  thoroughly  up  to  date.  We  know  of  no  more  satisfactory 
manual  than  this  one.  It  is  not  easy  to  particularize  its  excellent  features,  where 
there  are  so  many.  *  *  *  *  " 

From  "  The  Medical  Record,"  New  York : 

<i*  *  *  T^  chapter  on  general  hygiene  of  infants  and  children  engages 
the  attention.  This  chapter,  while  short,  nevertheless  contains  numerous  practical 
and  common  sense  views.  The  subject  of  feeding,  which  is  looked  for  with  interest 
in  every  work  on  diseases  of  children,  is  taken  up  from  many  standpoints.  *  *  * 
This  topic,  which  seems  to  be  the  bugbear  of  the  general  practitioner  on  account  of 
the  intricate  tables  usually  given,  is  here  presented  in  a  very  readable  manner  and 
quite  holds  the  attention.  *  *  The  article  on  diphtheria  is  one  of  the  best  of  the 
series.  It  is  thoroughly  up  to  date  and  gives  what  most  books  on  pediatrics  do  not — 
a  complete  discussion  from  every  standpoint  of  the  antitoxin  treatment.  Again,  intu- 
bation, which  is  too  often  hurriedly  passed  over  in  most  text-books,  finds  a  very  con- 
cise presentation  in  this  book.  Two  plates,  one  showing  the  method  of  after-feeding 
add  to  the  practicability  of  the  chapter.  *  *  " 


UERf  FY  OF 
OLLEGE  OF  OETEOFf-TKI 

M AN UAL 


DISEASES  OF  CHILDREN 


JOHN  MADISON  TAYLOR,  A.M.,  M.D. 

PROFESSOR  OF  DISEASES  OF  CHILDREN,  PHILADELPHIA  POLYCLINIC  ;  PEDIATRIST  TO  THE  PHILADEL- 
PHIA HOSPITAL;   ASSISTANT  PHYSICIAN  TO  THE  CHILDREN'S  HOSPITAL  AND  TO  THE  ORTHOPEDIC 
HOSPITAL;  NEUROLOGIST  TO  THE  HOWARD  HOSPITAL;  CONSULTING  PHYSICIAN  TO  THE 
ELWYN  AND  TO  THE  VINELAND  TRAINING  SCHOOLS  FOR  FEEBLE  MINDED  CHILDREN; 
FELLOW  OF  THE  COLLEGE  OF  PHYSICIANS  OF  PHILADELPHIA,  ETC.,  ETC. 


WILLIAM  H.  WELLS,  M.D. 


ADJUNCT   PROFESSOR   OF   OBSTETRICS   AND    DISEASES  OF  INFANCY  IN  THE  PHILADELPHIA  POLYCLINIC; 
DEMONSTRATOR  OF  CLINICAL  OBSTETRICS  IN  THE  JEFFERSON  MEDICAL  COLLEGE  CF  PHILADEL- 
PHIA ;    FELLOW  OF  THE  COLLEGE  OF   PHYSICIANS  OF  PHILADELPHIA  ;    MEMBER 
OF  THE   PHILADELPHIA   PEDIATRIC    SOCIETY,    ETC.,    ETC. 


SECOND  EDITION,  THOROUGHLY  REVISED  AND  ENLARGED 


Ullustratefc 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO. 

IOI2    WALNUT   STREET 
IQOI 


• 

• 


WJS2-OG 

I 


COPYRIGHT,  1901,  BY  P.  BLAKISTON'S  SON  &  Co. 


WM.   F.    FELL   &  CO., 

1220-24    8ANSOM    STREET, 
PHILADELPHIA. 


PREFACE  TO  SECOND  EDITION 


The  entire  book  has  been  thoroughly  rewritten,  and  a  number 
of  new  chapters  and  many  special  articles  are  added.  In  other 
directions  the  wording  has  been  condensed  and  some  repetitions 
and  elaborations  have  been  omitted  which  make  increased  clear- 
ness of  arrangement.  It  is  now  felt  that  the  book  will  be 
found  to  be  a  succinct  presentation  of  the  whole  subject  of 
diseases  of  children. 

Attention  is  called  to  the  remodeling  of  the  articles  on  infant 
feeding  ;  these  have  been  almost  entirely  rewritten,  owing  to  the 
great  advance  in  our  knowledge  of  the  subject,  especially  in 
regard  to  the  home  modification  of  milk.  The  articles  on  the 
diseases  incident  or  following  birth  and  the  diseases  of  the  diges- 
tive organs  have  been  carefully  revised. 

A  chapter  on  Diseases  of  the  Ear  is  added  ;  that  on  the  Blood 
is  practically  new  and  as  thorough  as  space  will  permit.  The 
chapter  on  Diseases  of  the  Nervous  System  is  carefully  revised 
and  several  articles  added  ;  that  on  the  Skin  is  again  rewritten  ; 
also  those  treating  on  Infectious  Diseases,  Diseases  of  the  Heart, 
and  the  Respiratory  Disorders,  much  new  matter  being  added. 

We  are  especially  indebted  to  Dr.  Geo.  C.  Stout  for  assistance 
in  the  article  on  disorders  of  the  ear ;  Dr.  Casper  Sharpless,  for 
that  on  the  blood  ;  Dr.  Naudain  Duer,  for  that  on  urinalysis  and 
disorders  of  the  kidney ;  Dr.  Chas.  N.  Davis,  for  that  on  the 
skin  ;  Dr.  Warmuth,  for  that  on  variola  and  vaccinia.  To  Dr. 
Alfred  R.  Allen,  Dr.  Jesse  Williamson,  Dr.  Charlotte  W.  West, 
and  Mr.  George  Ulrich  we  are  indebted  for  help  in  various  ways. 
The  index  was  compiled  by  Dr.  Leighton  F.  Appleman. 


PREFACE  TO  FIRST  EDITION 


The  authors  do  not  claim  this  book  to  be  a  treatise  on  the 
maladies  of  childhood.  The  original  manuscript  has  in  many 
cases  been  extensively  condensed  and  several  articles  omitted  so 
as  to  reduce  the  size  of  the  volume  to  its  due  proportions  as  a 
practical  working  manual — a  brief  but  competent  guide  for  the 
student  and  practitioner.  The  aims  of  the  authors  have  been  to 
present  in  a  clear  and  concise  manner  the  chief  points  in  the 
description,  differentiation,  and  treatment  of  the  diseases  of 
childhood.  The  pathology  has  been  abbreviated,  not  because 
this  most  important  division  of  the  subject  is  undervalued,  but 
for  the  reason  that  in  so  small  a  work  there  is  not  sufficient  room 
adequately  to  describe  the  constantly  increasing  discoveries  and 
opinions  in  this  direction.  The  treatment  of  the  various  diseases 
described  is  accorded  prominence,  and  has  in  the  majority  of 
cases  been  dwelt  on  at  length,  though  the  mention  of  many 
drugs  is  avoided.  The  authors  do  not  attempt  to  offer  much 
that  is  original  or  novel,  and  only  obtrude  their  individual  views 
when  commenting  upon  the  opinions  of  the  great  masters  in  the 
field  of  pediatric  medicine.  The  names  of  few  authorities  are 
mentioned.  In  the  preparation  of  the  manuscript  several  gentle- 
men have  most  kindly  lent  their  aid,  and  to  them  the  thanks  of 
the  authors  are  due.  Among  these  are  :  Dr.  Wm.  Johnson 
Taylor  has  added  much  of  interest  from  the  standpoint  of  the 
surgeon ;  James  Herbert  McKee,  on  diseases  of  the  heart ; 
T.  A.  Erck,  on  diabetes,  etc.  ;  Joseph  Leidy,  on  scurvy  ;  Carl 
Seiler,  A.  V.  Watson,  and  G.  H.  Makuen,  on  respiratory 
diseases.  The  authors  desire  also  to  acknowledge  their  in- 

vii 


41 

Viii  PKKK.U-K    TO    FIRST    EDITION. 

debtedness  to  Dr.  Van  Harlingen  for  aid  in  chapter  on  skin 
diseases  ;  to  Dr.  Edwin  Rosenthal  for  his  aid  in  the  article  on 
diphtheria  and  intubation  ;  to  Dr.  L.  S.  Ferris  for  numerous 
abstracts  on  the  literature  of  the  diseases  of  the  blood,  the  acute 
fevers,  etc.  ;  and  to  Dr.  L.  F.  Appleman  for  the  index. 


CONTENTS 


CHAPTER    I. 

PAGE 

PHYSIOLOGY  OF  THE  INFANT  AND  CHILD, 17 

General  Symptomatology  and  Diagnosis  of  Disease  in  Children,      ....  41 

CHAPTER  II. 

DISEASES  OCCURRING  AT  OR  NEAR  BIRTH 45 

Asphyxia  Neonatorum,  45 

The  Management  of  Infants  Prematurely  Born, 54 

DISEASES  IN  THE  NEW-BORN  CHARACTERIZED  BY  HEMORRHAGE, 59 

Hemorrhages  in  the  New-born, 59 

Apoplexy  in  the  New-born, 60 

Hemorrhages  from  Mucous  Surfaces, 62 

Caput  Succedaneum, 63 

Cephalhematoma, 64 

Hematoma  of  the  Sternocleidomastoid, 67 

Umbilical  Hemorrhage,  69 

Gastro-intestinal  Hemorrhage, 69 

DISEASES  CHARACTERIZED  BY  JAUNDICE, 70 

Icterus  in  the  New-born,  .  .  70 

Malignant  Jaundice  in  the  New-born, ,  .  71 

Acute  Hemoglobinuria  in  the  New-born, 72 

Acute  Fatty  Degeneration  in  the  New-born, 73 

DISEASES  PRODUCED  BY  SEPTIC  INFECTION, 74 

General  Septic  Infection  of  the  New-born,  74 

Omphalitis, 76 

Tetanus  in  the  New-born, 76 

Inspiration  Pneumonia, 77 

Sclerema,  78 

Melena  in  the  New-born, 79 

Mastitis  in  the  New-born, 80 

Obstetric  Paralysis, 81 

Umbilical  Polypi, 84 

Diverticulum  Tumor  and  Persistence  of  the  Omphalomesenteric  Duct,  .  .  85 

Umbilical  Hernia, 86 

CHAPTER  III. 

GENERAL  HYGIENE  OF  INFANTS  AND  CHILDREN 88 

CHAPTER    IV. 

FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN, 94 

Feeding  from  the  Breast, 94 

Weaning,      loo 

ix 


X  CONTENTS. 

PAGE 

Feeding  by  a  Wet-nurse, IO4 

Feeding  by  the  Use  of  Modified  Milk  of  Animals, .  105 

Decomposition  and  Bacteriology  of  Milk,    .    .  no 

The  Breeds  of  Cows  Best  Adapted  for  Infant  Feeding, 119 

Supervision  of  the  Production  of  Milk  by  Boards  of  Health, 121 

Sterilization  and  Pasteurization, 123 

Modified  Milk 126 

Diet  of  Children  from  the  Sixth  to  the  Eighteenth  Month, 143 

Diet  of  Children  from  the  Second  Year, 147 

CHAPTER  V. 

DISEASES  OF  THE  DIGESTIVE  ORGANS, 155 

I  MM  uses  of  the  Mouth,  156 

Stomatitis, 156 

Diseases  of  the  Tongue, 165 

Fibrinous  Macroglossia,  1 66 

Glossitis, 167 

Ranula, 167 

Dentition,  Normal  and  Delayed, 168 

Diseases  of  the  Esophagus, 1 73 

Esophagitis, 173 

Diseases  of  the  Stomach, 174 

Gastritis,  . 174 

Chronic  Gastritis, 178 

Cyclic  Vomiting,  183 

Pyloric  Hypertrophy  with  Stenosis, \  .  184 

Ulcer  of  the  Stomach  in  Children,  .  . 185 

Gastralgia,  ...  190 

Dilatation  of  the  Stomach, 191 

Diseases  of  the  Intestines,  192 

Malformations  of  the  Intestinal  Tract,  192 

Acute  Enteritis, 193 

Chronic  Enteritis, 195 

Acute  Milk  Infection, 200 

Subacute  Milk  Infection, .  206 

Ileocolitis, 211 

Amyloid  Degeneration  of  the  Intestines, 218 

Mucous  Disease,  218 

Chronic  Constipation,  224 

Intestinal  Colic, 227 

Intestinal  Obstruction, 230 

Hernia, 235 

Diseases  of  the  Rectum, 237 

Prolapse  of  the  Rectum, 237 

Rectal  Polypi,  238 

Prolapse  of  the  Anus, 239 

Fissure  of  the  Anus, 240 

Ischiorectal  Abscess,  .  241 

Hemorrhoids, 241 

Incontinence  of  Feces, 241 

Proctitis 241 

CHAPTER  VI. 

DISEASES  OF  THE  PERITONEUM, 244 

Appendicitis,  2. . 

Tuberculosis  of  the  Peritoneum, 2152 

INTESTINAL  PARASITES, 254 


CONTENTS.  XI 
CHAPTER  VII. 

PAGE 

DISEASES  OF  THE  LIVER, 264 

Jaundice  Occurring  During  Childhood, 267 

Congestion  of  the  Liver, 270 

Physical  Signs  of  Hepatic  Abscess, 271 

Multiple  Hepatic  Abscess,      272 

Syphilitic  Inflammation  of  the  Liver, 273 

Suppurative  Inflammation  of  the  Liver, 273 

Interstitial  Hepatitis, 274 

Fatty  Liver, 278 

Amyloid  Disease  of  the  Liver, 279 

Acute  Yellow  Atrophy  of  the  Liver, 280 

Hydatid  Disease, 281 

CHAPTER  VIII. 

DISEASES  OF  THE  GENITO-URINARY  SYSTEM, 284 

The  Urine, 284 

Anuria, 285 

Polyuria, 286 

Physiologic  Glycosuria, 286 

Indicanuria,  287 

Acetonuria, 288 

Pyuria,  289 

Hematuria, 289 

Hemoglobinuria,  291 

Enuresis, 291 

Stone  in  the  Bladder, 295 

Cystitis, 298 

Physiologic  Albuminuria, 300 

DISEASES  OF  THE  KIDNEY, .  .  301 

Acute  Congestion  of  the  Kidney, 301 

Chronic  Congestion  of  the  Kidney, 301 

Acute  Degeneration  of  the  Kidney,  302 

Acute  Exudative  Nephritis, 303 

Acute  Diffuse  Nephritis, 305 

Chronic  Nephritis, 309 

Perinephritis, 314 

Pyelitis, 315 

Renal  Calculi,  316 

Tuberculosis  of  the  Kidney,  317 

Tumors  of  the  Kidney, 318 


CHAPTER   IX. 

DISEASES  OF  THE  GENITAL  ORGANS, 319 

Adherent  Prepuce  and  Phimosis, 319 

Paraphimosis, ,  320 

Balanitis, 321 

Vulvovaginitis, 321 

Orchids,    ....  322 

Tubercular  Disease  of  the  Testicle, 322 

Epididymitis, 323 

Hydrocele,    .  323 

Undescended  Testicle, 325 

Torsion  of  the  Spermatic  Cord, 325 

Hypospadias, 325 

Epispadias, 326 


XJj  CONTENTS. 

CHAPTER  X. 

DISEASES  OF  THE  BLOOD, 327 

General  Considerations  and  Definitions, '  «e 

Anemia, ^i 

Primary  Anemias, '  ' 

Chlorosis,      3.35 

Simple  Primary  Anemia -«y 

Splenic  Anemia, 34 

Leukocythemia, 34 

Pseudoleukocythemia  Infantum, 345 

Progressive  Pernicious  Anemia, 345 

Hodgkin's  Disease,     ...        349 

Secondary  Anemia,      35° 

CHAPTER  XI. 

CONSTITUTIONAL  DISEASES, 355 

Rheumatic  Fever, 355 

Muscular  Rheumatism, 3°2 

Chronic  Rheumatism, 3°3 

Rheumatic  Phlebitis, 3°3 

Rachitis, 304 

Scorbutus, 375 

Simple  Atrophy, 379 

Diabetes  Mellitus, 3»5 

Uric  Acid  and  Uric  Acid  Conditions, 389 

CHAPTER  XII. 

DISEASES  OF  THE  HEART, 391 

General  Considerations,  391 

Congenital  Diseases  of  the  Heart, 395 

Functional  Disturbances  of  the  Heart, 39° 

Organic  Cardiac  Diseases, .•  4°° 

Diseases  of  the  Pericardium,  4°3 

Pericarditis,  4°3 

Other  Affections  of  the  Pericardium, 4°7 

Affections  of  the  Myocardium, 4°7 

Myocarditis, 4°8 

Diseases  of  the  Endocardium, 4IQ 

Endocarditis, 4IQ 

CHAPTER  XIII. 

DISEASES  OF  THE  RESPIRATORY  ORGANS, 422 

Disorders  of  the  Upper  Respiratory  Tract, 422 

Acute  Rhinitis, .  42° 

Chronic  Rhinitis  (Simple  and  Hypertrophic), 427 

Purulent  Rhinitis, 42$ 

Atrophic  Rhinitis, 42& 

Croupous  or  Membranous  Rhinitis, 429 

Syphilitic  Rhinitis, 429 

Mucous  Polypi  (Edematous  Fibromata), 429 

Fibrous  Tumors,  43° 

Adenoid  Vegetations,       430 

Acute  Pharyngitis,  43° 

Rheumatic  Pharyngitis, 431 

Retropharyngeal  Abscess  (Retropharyngeal  Lymphadenitis),    ....  431 

Tonsillitis,     ......  433 

Chronic  Tonsillitis  (Hypertrophy  of  the  Tonsils), 437 

Disorders  of  Speech 437 

Croup, 440 

Membranous  Croup, 445 


CONTENTS.  Xlll 

PAGE 

Laryngismus  Stridulus, 449 

Cough,       .  450 

Acute  Bronchitis, 452 

Chronic  Bronchitis,      457 

Bronchial  Asthma, 458 

Pulmonary  Emphysema, 462 

Acute  Bronchopneumonia,      463 

Chronic  Bronchopneumonia, 469 

Croupous  Pneumonia, 471 

The  Treatment  of  Pneumonia, 476 

Pleurisy,             ....        483 

Pleuropneumonia, 490 

Empyema, 492 

CHAPTER  XIV. 

DISEASES  OF  THE  NERVOUS  SYSTEM, 495 

Nervous  Manifestations  in  the  Diseases  of  Children, 495 

The  Neuron, ....  499 

Reflexes — Their  Physiology  and  Significance, 500 

Motor  Excitements,     . 504 

Convulsions, 504 

Tetany, 511 

Automatic  Movements,        517 

Epilepsy,      521 

Chorea,      .        528 

Insanity  and  Disturbances  of  the  Mind  in  Children, 537 

Imbecility,  Feeble-mindedness,  and  Idiocy, 540 

Hysteria  in  Childhood  and  Youth, 546 

Hydrocephalus, 553 

Exophthalmic  Goiter,      555 

Raynaud's  Disease, 557 

Myxedema,       558 

Migraine,      559 

Neuritis, , 561 

Multiple  Neuritis, 561 

Diphtheric  Paralysis, 565 

Lead  Paralysis, 566 

Tetanus, 5^7 

Simple  Cerebral  Meningitis, 570 

Simple  Posterior  Basic  Meningitis, 574 

Tubercular  Meningitis, 575 

Infantile  Cerebral  Palsies, 578 

Tumors  of  the  Brain  and  Its  Meninges, 585 

Abscess  of  the  Brain, 589 

Infantile  Spinal  Paralysis, , 5^9 

Acute  Myelitis, 594 

Disseminated  Sclerosis, 599 

Hereditary  Ataxia, 601 

Progressive  Muscular  Atrophies, 602 

Pseudohypertrophic  Muscular  Paralysis, 603 

CHAPTER  XV. 

THE  SPECIFIC  INFECTIOUS  DISEASES, 605 

Tuberculosis, 605 

General  Tuberculosis, 609 

Tuberculosis  of  the  Lungs, 610 

Typhoid  Fever, 619 

Diphtheria, 632 

Tracheotomy, 656 


xiv  CONTENTS. 

PAGE 

Intubation  of  the  Larynx 658 

Scarlet  Fever, 666 

Variola, 680 

Vaccinia, 685 

Varicella,      687 

Malarial  Fever, 689 

Epidemic  Influenza, 700 

Epidemic  Cerebrospinal  Meningitis,      706 

Mumps, Jil 

\Yhooping-cough, 713 

Syphilis, "Ji8 

Measles, 729 

Rubella, 735 

The  Bubonic  Plague 738 

Glandular  Fever, 741 

Care  and  Treatment  of  the  Hair  in  Acute  Infectious  Diseases, 741 

CHAPTER  XVI. 

DISEASES  OF  THE  SKIN, 743 

Aphthous  Vulvitis  of  Children, 743 

Dermatitis,        743 

Ecthyma,       • 746 

Eczema, 747 

Erythema, 760 

Furuncle, 763 

Herpes  Zoster, 764 

Impetigo  Contagiosa, i    .  766 

Miliaria,         767 

Pediculosis,       769 

Pityriasis  Rosea, 770 

Psoriasis, 770 

Purpura, 771 

Scabies, 773 

Seborrhea 774 

Tinea  Trichophytina, 775 

Tinea  Circinata, 777 

Tinea  Favosa, ...  778 

Urticaria,      779 

CHAPTER  XVII. 

DISEASES  OF  THE  EAR, 781 

Diseases  of  the  External  Ear, 783 

Diseases  of  the  Middle  Ear, 785 

Diseases  of  the  Internal  Ear, 791 

CHAPTER   XVIII. 

GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT, 792 

Feebleness  in  Girls  about  the  Age  of  Puberty, 811 

CHAPTER  XIX. 

CONDITIONS  REQUIRING  SURGICAL  PROCEDURES, 818 

Lymphadenitis, _  818 

Injuries  and  Shock, 822 

Harelip. — Cleft  Palate, .    .    .    .  823 

Diseases  of  the  Joints, 824 

Infectious  Osteitis  (Osteomyelitis), 826 

Ophthalmia  in  the  New-born, 826 

INDEX, 829 


YMt  ftftrfc  t&UKt  OF  OSTtOi  A]  ,  : . 


LIST  OF  ILLUSTRATIONS 


FIG.  PAGE 

1.  Dissection    of  a  New-born  Infant,  showing  the  Size  and  Position  of  the 

Thymus  Gland  and  its  Relation  to  the  Lungs, 24 

2.  Schultze's  Method  (Inspiration), 48 

3.  Schultze's  Method  (Expiration), 49 

4.  Sylvester's  Method  (Expiration), 51 

5.  Sylvester's  Method  (Inspiration), 51 

6.  Artificial  Respiration  (Inspiration), 52 

7.  Artificial  Respiration  (Expiration), 52 

8.  Ribmont's  Tube, 53 

9.  Diagram  of  Tarnier  Couveuse, 54 

JO.    Breck's  Infant  P'eeder, 56 

11.  Modification  of  Tarnier  Couveuse,  in  Use  in  the  Jefferson  Maternity,  Phila- 

delphia,       57 

12.  Section  of  Cephalhematoma, 65 

13.  Hematoma  of  the  Sternocleidomastoid  (from  a  patient  in  the  Philadelphia 

Polyclinic}, 68 

14.  Diagram  Illustrating  the  Effects  of  the  Persistence  of  the  Omphalomesen- 

teric  Duct   and   the  Formation   of  the   So-called  Diverticulum  Tumor 

(Riesmaii), 85 

15-  A.  Marchand's  Tube.     B.  C.  Holt's  Lactometer  and  Cream  Gage,    ...  114 

16.  Feser's  Lactoscope, 115 

17.  Twelve  Per  Cent.  Cream, 117 

1 8.  Estran's  Materna, 140 

19.  Gangrenous  Stomatitis  (Dr.  Stengel's  Case  at  the  Children's  Hospital},  .    .  162 

20.  Macroglossia  (Dr.   W.  W.  Keen' s  Case}, 1 66 

21.  Diagram  Showing  the  Order  of  the  Eruption  of  the  Milk-teeth 170 

22.  Diagram  Showing  the  Order  of  Eruption  of  the  Permanent  Teeth  (From 

Rotch], 171 

23.  Subacute  Milk  Infection  (From  patient  in  the  Department  of  Obstetrics  and 

Diseases  of  Infancy,  Polyclinic  Hospital,  Philadelphia), 207 

24.  Taenia  Nana,  von  Siebold  (After  Leuckart),  X  IO. 260 

25.  Head   of  Taenia   Nana,   von  Siebold  ;    with  Retracted  Rostellum  (After 

Leuckart},  X  75-     A.   An  isolated  hook,  X  3°°> 260 

26.  Egg  of  Taenia  Nana,  von  Siebold  (After  Leuckart},  X  3°o, 260 

27.  Taenia  Saginata,  Goeze  (After  Leuckart), 261 

28.  Cephalic  End  of  Taenia  Saginata,  Goeze  (After  Leuckart] — A  in  retracted 

and  B  in  extended  state, ,    .  261 

xv 


xvi  LIST    OF    ILLUSTRATIONS. 

FIG.  PACK 

29.  Head  of  Tsenia  Solium  ;  On  the  Right,  Egg  of  Trcnia  Solium  (Leuckart),     262 

30.  Diagram  Showing  Reflex  Nerve  Arc  of  the  Act  of  Micturition, 293 

31.  a.   Small  Lymphocyte,     b.   Large  Lymphocyte,     c.   Transitional  Lympho- 

cyte,    d.    Neutrophiles.     e.   Eosinophiles.    f.   Myelocytes.     g.    Eosin- 
ophilic  Myelocyte, 328 

32.  a.   Normocyte..    b.   Parasites  of  quartan  fever,     c.   Parasites  of  tertian  fever. 

d.   Parasites  of  estivo-autumnal  fever, 328 

33.  a.  Normocyte.     b.   Normocyte  Deficient  in  Hemoglobin,     c.   Poikilocytes. 

d.   Macrocyte.     e.   Microcyte.     f.    Normoblasts.     g.    Megaloblasts.      //. 
Poikiloblast.      i.   Microblast, 328 

34.  Human  Colored  Blood-corpuscles  (After  Landois) — I.   On  the  flat.      2.  On 

edge.     3.   Rouleau  of  corpuscles, 335 

35.  Acute  Atrophy  (Acute  Marasmus)  (From  patient  in  the  Department  of  Ob- 

stetrics and  Diseases  of  Infancy,  Polyclinic  Hospital,  Philadelphia],    .    .     380 

36.  Acute  Parenchymatous  Nephritis  and  Hematuria,  Showing  Decided  Left 

Ventricular  Hypertrophy ;  Area  of  Dullness  Outlined  by  Auscultatory 
Percussion, 408 

37.  Girl  Aged  Eleven  Years  ;  Double  Mitral  Disease,  Area  of  Dullness  Greatly 

Increased,  Especially  Over  the  Left  Ventricular  Region, 411 

38.  Improvised  Croup  Tent,  Made  from  an  Umbrella  and  a  Sheet, 446 

39.  Tuberculosis  of  the  Lungs  Developing  during  Typhoid  Fever, 607 

40.  Skiagram  of  a  Well -developed  Male   Infant   a   Few    Hours   After   Birth 

(O'Dwyer's  Intubation  Tube  Still  in  the  Throat), 633 

41.  Method  of  Feeding  Child  after  Intubation, 659 

42.  Method  of  Introducing  the  O'Dwyer  Tube  in  Intubation, 66 1 


MANUAL 


DISEASES  OF  CHILDREN. 


CHAPTER   I. 
PHYSIOLOGY  OF  THE  INFANT  AND  CHILD. 

SIZE  AND  WEIGHT. 

A  fully  developed  infant  is  one  born  after  a  period  of  two 
hundred  and  eighty  days'  gestation.  The  average  length  at 
birth  is  from  seventeen  to  twenty  inches,  or  about  fifty  centime- 
ters, and  the  weight,  as  given  by  different  authorities,  varies  from 
six  to  eight  pounds  (averaging  about  4000  gm.).  The  weight 
of  males  is  slightly  in  excess  of  that  of  females. 

The  weight  of  the  infant  and  child,  although  subject  to  slight 
variations  due  to  many  causes,  should  increase  in  a  regular,  defi- 
nite proportion  according  to  the  age.  Sudden  decrease  in 
weight  almost  certainly  points  to  some  fault  in  nutrition,  the  use 
of  improper  foods,  or  the  approaching  onset  of  some  disease. 

The  average  infant  will  double  its  initial  weight  between  the 
fifth  and  sixth  months,  and  will  treble  it  at  about  fifteen  months. 
At  seven  years  the  weight  is  double  that  of  one  year,  and  at  the 
fourteenth  year  it  is  double  that  of  seven  years.  It  has  been 
pointed  out  by  Proscher  that  the  growth  of  the  infant  during  the 
period  of  suckling  increases  in  proportion  to  the  richness  of  the 
mother's  milk  in  proteids  and  salts,  and  that  this  law  applies  to 
other  animals  as  well  as  to  man,  the  young  of  those  animals  whose 
milk  is  especially  rich  in  proteids  and  salts  increasing  in  weight 
more  rapidly  than  others. 

17 


18 


PHYSIOLOGY    OF    THE    INFANT    AND    CHILD. 


He  states  that  an  infant  fed  on  mother's  milk  with  an  average 
of  1.86  per  cent,  of  proteids  should  double  its  initial  weight  in 
one  hundred  and  eighty  days. 

The  following  table  will  show  the  gain  in  weight  in  grams  and 
pounds  from  birth  to  fourteen  years  : 


AGE. 

GRAMS. 

POUNDS. 

AVERAGE  GAIN  A  DAY. 

Grams. 

Ounces. 

At  birth            

3000  to  4000 

9,500 
19,000 
38,000 

6.6  to  8.8 

20.9 
41.8 
83.6 

20  to  30 
10  to  20 

%  to  I 

1A  to  % 

From  birth  to  five  months,     . 
From  five  months  to  twelve 
months     

At  one  year,     

At  seven  years,    

At  fourteen  years,   

The  above  table  is  computed  on  a  basis  of  3500  gm.  (7.7 
pounds)  at  birth,  and  of  a  gain  of  30  gm.  a  day  for  the  first 
four  months  and  10  gm.  a  day  for  the  last  eight  months  of  the 
first  year  (Rotch). 


BOYS. 

• 

GIRLS. 

Height, 
Inches. 

Weight, 
Pounds. 

AGE. 

Height, 
Inches. 

Weight, 
Pounds. 

19-75 

7-15 

Birth. 

19.25 

6-93 

24-75 

14-3 

5  months. 

23-25 

13.86 

29-53 

20.98 

I  year. 

29.67 

19.8 

33-82 

30.36 

2  years. 

32-94 

29.28 

37.06 

34.98 

3 

36.31 

33-15 

39-31 

37-99 

4 

38.8 

36.36 

41-57 

4i 

5 

41.29 

39-57 

43-75 

45.07 

6 

43-35 

43-18 

45-74 

48.97 

7 

45-52 

47-3 

47.76 

53-8i 

8 

47.58 

5I-56 

49.69 

59 

9 

49-37 

57 

51.68 

65.16 

10 

Si-34 

62.23 

53-33 

70.04 

ii 

53-42 

68.7 

55-" 

76.75 

12 

55-88 

78.16 

57-21 

84.67 

13 

58.16 

88.46 

59-88 

94-49 

H 

59-94 

98.23 

It  is  a  curious  fact  that  in  comparing  the  weights  of  children  as  shown  in  the  above 
table  (which  refers  to  the  proportion  of  height  to  weight  in  American  children)  with 
those  as  found  in  the  works  of  certain  English  authors,  the  weight  of  American  seems 
to  be  slightly  under  that  of  foreign  children  of  the  same  height  and  age. 


SIZE    AND    WEIGHT.  1 9 

During  the  first  six  months  the  increase  in  length  of  the  ave- 
rage infant  is  from  4  to  5  inches  ;  in  the  second  half  of  its  first 
year  the  increase  is  from  3  to  4  inches  ;  during  the  second  year 
the  gain  is  from  3  to  5  inches  ;  during  the  third  year,  from  2  to 
3  y2  inches  ;  and  in  the  fourth  year,  from  2  to  3  inches.  From 
this  time  on  the  increase  in  length  averages  about  from  i  ^  to  2 
inches  every  year.  The  length  of  the  child  at  any  given  age 
should  bear  some  sort  of  relation  to  its  weight ;  this  is  shown 
in  the  second  table  on  page  18. 

Slow  or  arrested  growth,  if  continuous,  is  always  a  sign  of 
some  pathologic  condition.  The  most  common  of  these  is  malas- 
similation  of  food,  but  more  serious  conditions,  such  as  rickets  or 
syphilis,  must  be  considered.  Arrested  growth  is  very  com- 
monly found  in  children  affected  with  chronic  diseases  of  the 
brain  and  in  cretins. 

In  infancy  the  tissues  are  softer  and  more  elastic  than  those  of 
the  adult  or  even  of  older  children.  The  body  and  limbs  are 
well  rounded  by  a  plentiful  covering  of  fat,  giving  the  character- 
istic plumpness  and  roundness  so  familiar  in  the  infantile  form.  A 
downy  growth,  known  as  lanugo,  frequently  covers  the  body  at 
this  time ;  the  nails  are  well  formed,  and  extend  to  the  end  of 
the  pulp  of  the  fingers  and  toes.  A  glance  at  the  body  as  a 
whole  will  at  once  reveal  the  fact  that  the  upper  part  of  the  trunk, 
with  the  arms  and  head,  is  much  larger  than  the  lower  part  of 
the  body,  with  the  exception  of  the  abdomen.  The  cause  of  this 
will  easily  be  seen  when  we  study  the  changes  in  the  circulation 
of  the  blood  which  follow  the  cessation  of  placental  and  the 
establishment  of  pulmonary  circulation.  It  has  been  taught  by 
the  older  writers  that  the  general  aspect — the  roundness  of  body 
and  limbs,  the  formation  of  the  nails,  the  plentiful  growth  of  hair 
on  the  head,  and  the  attainment  of  the  average  weight — is  suffi- 
cient evidence  of  normal  development  of  the  infant  at  birth.  Yet 
observations  made  on  a  large  number  of  infants  show  us  that 
certain  parts  of  the  infant's  body  must  attain  certain  definite  rela- 
tions to  one  another  in  regard  to  size,  in  order  to  show  that  it 
has  attained  a  perfect  state  of  development.  A  short  rule  for 
computing  this  is  the  following  :  As  has  been  before  stated,  the 
length  of  the  average  child  at  birth  is  about  20  inches,  or  50  cm. 
If  the  infant  is  normally  developed,  the  circumference  of  the  tho- 
rax should  measure  one-half  the  entire  length  of  the  body  plus  10 
(50  divided  by  2  equals  25  ;  plus  10,  equals  35  cm.).  Therefore 
35  cm.  is  the  circumference  of  the  thorax  in  the  normal  infant. 
The  circumference  of  the  skull  should  equal  the  circumference  of 
the  thorax  plus  2,  or  37  cm.  (50  divided  by  2,  plus  10,  equals  35  ; 


2O  PHYSIOLOGY    OF    THE    INFANT    AND    CHILD. 

plus  2,  equals  37  cm.).  This  simple  rule  is  of  practical  value,  and 
has  been  tested  by  the  authors  in  a  number  of  cases.  According 
to  Frank,  who  has  made  a  series  of  studies  on  the  relative  size  of 
the  head  and  of  the  shoulders  of  infants  born  at  term,  the  girth 
of  the  shoulders  is  usually  greater  than  that  of  the  head.  When 
the  circumference  of  the  head  falls  below  32  cm.  (12^  inches), 
the  child  is  usually  immature.  The  growth  of  the  finger-nails,  the 
presence  of  lanugo,  and  the  size  of  the  epiphyses  he  considers 
of  little  importance  as  diagnostic  signs  of  the  maturity  of  the 
fetus.  Changes  in  the  proportions  given  above  in  a  majority  of 
cases  will  point  to  some  abnormality  in  the  development  of  the 
child  or  to  the  presence  of  disease  ;  thus,  when  the  circumference 
of  the  head  greatly  exceeds  its  relative  proportion  to  the  thorax 
and  length  of  the  infant,  the  patient  is  either  rachitic  or,  more 
probably,  has  beginning  hydrocephalus.  A  considerable  decrease 
in  these  proportions  would  very  probably  indicate  microcephalus, 
and  if  the  fontanels  are  absent  or  very  small,  the  diagnosis  would 
be  almost  certain. 

An  examination  of  the  trunk  and  extremities  of  the  new-born 
infant  will  reveal  the  fact  that  the  former  is  ovoid  in  shape  with 
the  larger  end  below,  the  greater  part  of  this  lower  end  being 
taken  up  by  the  abdomen,  which  at  this  period  of  life  is  large  in 
proportion  to  the  rest  of  the  body.  The  reason  for  this  will  be 
explained  when  we  study  the  proportionate  size  of  the  various 
abdominal  organs,  especially  the  liver,  which  during  fetal  life  and 
infancy  is  of  a  size  out  of  all  proportion  to  the  other  abdominal 
organs.  The  pelvis  and  lower  extremities  are  proportionately 
small  and  ill  developed,  while  the  upper  extremities  "appear  as 
small,  jointed  outgrowths  from  the  smaller  end  of  the  ovoid 
trunk." 

Usually  the  first  spontaneous  act  of  the  new-born  infant  is  a 
lusty  cry.  By  this  means  air  is  inspired  into  the  lungs,  which 
expand  for  the  first  time,  and  thus  aid  in  establishing  pulmonary 
respiration.  When  nude  and  lying  on  its  back,  we  see  the  new- 
born infant  making  almost  continuous  movements  with  the  legs 
and  arms,  accompanied  by  a  certain  amount  of  flexion  and  exten- 
sion of  the  spine.  These  movements  are  probably  a  continuation 
of  those  made  in  the  uterus  during  fetal  life.  When  asleep,  the 
attitude  is  normally  one  of  complete  repose,  there  being  no  mo- 
tion except  that  of  respiration,  the  type  of  which  may  vary  con- 
siderably even  in  health. 


TEMPERATURE CIRCULATION.  2  I 


TEMPERATURE. 

At  birth  the  rectal  temperature  of  the  infant  is  about  100°  F. 
(37-5°  C.),  the  axillary  temperature  being  about  two  degrees 
lower.  According  to  some  authorities,  a  slight  fall  of  two  or 
three  degrees  occurs  a  short  time  after  birth  ;  this,  however,  in 
the  course  of  a  few  hours  rises  to  98.5°  F.,  which  is  the  normal 
temperature  of  the  human  body.  Rotch  gives  the  temperature 
of  the  new-born  as  follows  : 

At  birth, 37  2°  C.  (99°  F.) 

Within  an  hour, 36.1°  to  35.5°  C.  (97°  to  96°  F.) 

In  about  a  week, 36.8°  C.  (98.2°  F.). 

There  is,  however,  in  all  cases  a  certain  amount  of  variation 
which  must  be  considered  to  be  within  the  normal  limit.  This  nor- 
mal variation  is  considerably  greater  in  infants  than  in  adults,  with 
the  exception  of  the  temperature -ranges  seen  in  women  during 
the  puerperal  period.  In  premature  infants  or  in  those  whose 
development  is  under  the  average  at  birth  the  temperature  is  apt 
to  be  below  the  figures  which  have  been  given.  Reitz  and  Fin- 
layson  have  shown  that  there  is  a  slight  variation  in  temperature 
at  different  times  in  the  day  :  the  highest  point  being  between  5 
and  6  P.M.,  and  the  lowest  occurring  during  the  early  morning 
hours,  say  between  4  and  5  A.M.  It  is  of  importance  to  remem- 
ber that  in  young  children  trifling  causes  may  often  produce  con- 
siderable increase  in  bodily  heat.  An  example  of  this  is  seen 
in  the  fever  which  accompanies  various  slight  nutritive  dis- 
turbances. 

CIRCULATION. 

Previous  to  birth,  the  course  of  the  circulation  in  the  fetus  is 
as  follows  :  The  fetal  blood,  separate  and  distinct  from  the  ma- 
ternal, flows  from  the  placenta  through  the  umbilical  vein  and 
enters  the  body  at  the  umbilicus,  passing  thence  directly  to  the 
liver.  At  this  point  a  division  in  the  current  takes  place,  part 
of  it  passing  through  the  ductus  venosus  to  the  inferior  or  as- 
cending vena  cava,  the  remaining -portion  going  directly  into  the 
portal  vein  and  passing  through  the  liver  ;  it  then  enters  the 
ascending  vena  cava,  whence  it  goes  into  the  heart  at  the  right 
auricle.  Here  the  blood  currents  from  the  superior  and  the 
inferior  vena  cava  empty,  but  do  not  unite,  and  instead  of  pass- 
ing into  the  right  ventricle,  as  is  the  case  in  adults,  the  blood  is 
directed  by  the  Eustachian  valve  into  the  left  auricle  through  the 
opening  known  as  the  foramen  ovale.  Thence  it  passes  into  the 


22  PHYSIOLOGY    OF   THE    INFANT    AND    CHILD. 

left  ventricle,  and  so  into  the  aorta,  whence  it  is  finally  distrib- 
uted through  the  general  system.  The  greatest  amount  of  blood 
containing  the  most  oxygen  is  carried  by  way  of  the  carotid  and 
subclavian  arteries  to  the  head  and  upper  extremities  ;  this 
accounts  for  the  great  development  of  the  latter  at  birth.  Re- 
turning from  the  upper  part  of  the  body,  the  venous  blood  is 
carried  along  the  superior  vena  cava  into  the  right  auricle,  from 
which  it  passes  through  the  tricuspid  valve  into  the  right  ventri- 
cle, and  thence  into  the  pulmonary  arteries  in  the  same  manner 
as  in  the  adult.  From  the  pulmonary  artery  a  small  quantity 
of  blood  is  allowed  to  pass  through  the  lungs,  but  the  greatest 
portion  of  it  is  carried  through  a  tube  which,  during  fetal  life, 
connects  the  pulmonary  artery  with  the  aorta,  and  which  is 
known  as  the  ductus  arteriosus.  By  this  avenue  it  is  carried  into 
the  aorta.  The  amount  of  blood  which  passes  directly  through 
the  pulmonary  arteries  into  the  lungs  is  only  sufficient  for  their 
nourishment,  and  the  return  circulation  then  passes,  as  in  the 
adult,  through  the  pulmonary  veins  entering  the  left  auricle, 
where  it  mingles  with  the  blood,  passing  by  way  of  the  foramen 
ovale,  and  thus  enters  the  aorta.  Subsequently  the  blood,  .laden 
with  the  excrementitious  substances  of  the  fetus,  is  carried  back 
to  the  placenta  through  the  umbilical  arteries.  These  are  con- 
tinuations of  the  right  and  left  hypogastric  arteries  which  arise 
from  the  internal  iliac  arteries.  The  changes  in  the  circulation 
following  birth  and  the  cutting-off  of  the  placental  circulation 
are  as  follows:  (i)  Expansion  of  the  lungs  produces,  by  de- 
grees, a  closure  of  the  foramen  ovale,  thus  relieving  aortic  pres- 
sure and  producing  obstruction  of  the  ductus  arteriosus,  which 
gradually  degenerates  into  a  fibrous  cord.  At  times  neither 
the  closure  of  the  foramen  ovale  nor  of  the  ductus  arteriosus 
occurs  immediately  after  birth  ;  indeed,  the  foramen  ovale  may 
remain  open  for  a  month  and  the  ductus  arteriosus  for  a 
considerably  longer  time.  (2)  The  umbilical  vein  and  the 
ductus  venosus  become  obliterated,  usually  from  the  second  to 
the  fifth  day  after  birth  ;  ultimately  they  degenerate  and  become 
fibrous  cords,  the  former  becoming  the  round  ligament  of  the 
liver  and  the  latter  a  fibrous  cord,  which  in  the  adult  may  be 
traced  along  the  fissure  of  the  ductus  venosus.  (3)  The  umbili- 
cal arteries  change  in  a  twofold  manner :  the  portion  between 
the  internal  iliac  and  the  superior  vesical  branch,  which  supplies 
the  bladder,  remains  pervious,  while  the  portion  between  the 
fundus  of  the  bladder  and  the  umbilicus  becomes  obliterated, — 
usually  from  the  second  to  the  fifth  day, — and  continues  as  a 
fibrous  cord  which  forms  the  lateral  ligaments  of  the  bladder.  (4) 


HEART.  23 

The  Eustachian  valve  ceases,  so  far  as  its  function  is  concerned, 
almost  immediately  after  birth.  Its  remains,  however,  may  be 
traced  for  weeks  or  months  afterward.  In  the  new-born  infant 
the  weight  of  the  blood  is  estimated  at  5  per  cent.  (^  to  -^)  of 
the  entire  body  weight,  while  in  the  adult  it  is  about  8  per  cent. 
(TS")  °f  the  D°dy  weight. 

HEART. 

In  its  early  stage  of  development  the  heart  is  so  large  as  to 
occupy  the  greater  part  of  the  thoracic  cavity.  According  to 
McClellan,  it  is  at  this  time  much  larger,  proportionately,  than  at 
any  later  period,  or  even  subsequent  to  birth.  The  relative  size 
of  its  cavities  is  also  different  at  this  time,  the  auricles  being  con- 
siderably larger  than  the  ventricles,  and  the  right  auricle  being 
the  larger  of  the  two.  As  the  organ  progresses  in  its  develop- 
ment we  find  the  ventricles  gradually  equal  and  then  exceed  the 
auricles  in  size.  The  peculiarities  of  structure  of  the  fetal  heart 
have  already  been  dwelt  upon  under  the  head  of  fetal  circulation  ; 
they  may,  however,  be  summed  up  briefly  in  the  following : 
Between  the  right  and  the  left  auricle  we  find  an  oval  opening, 
known  as  the  foramen  ovale,  which  allows  the  passage  of  the 
blood  between  the  two  auricles  ;  also  the  Eustachian  valve,  which 
directs  the  blood  coming  from  the  inferior  vena  cava  through  the 
foramen  ovale. 

Afterbirth  and  subsequent  to  the  commencement  of  pulmonary 
respiration,  with  the  complete  establishment  of  the  function  and 
structure  of  the  lungs,  we  find  these  organs  filling  out  their  nat- 
ural space  in  the  thorax,  and  after  this  the  heart  attains  nearly 
the  proportionate  size  to  the  other  organs  that  it  does  in  the 
adult,  and  its  position  will  be  found,  by  external  examination,  to 
be  very  nearly  the  same.  It  is  not,  however,  covered  by  the 
lungs  to  so  great  an  extent  as  in  the  adult,  and  this  difference  is 
caused,  partly,  by  the  presence  of  the  thymus  gland.  External 
examination  during  infancy  will  show  that  the  cardiac  impulse  is 
higher  and  extends  further  beyond  the  mammary  line  than  in  the 
adult,  and  that  its  apex-beat  is  often  obscure.  We  know,  how- 
ever, that  the  apex-beat  occupies  a  higher  position  and  is  further 
to  the  left  side  of  the  thorax  in  the  infant  than  in  the  older  child. 
Later  in  childhood  the  apex  can  be  made  out  with  great  clear- 
ness ;  in  fact,  is  often  more  distinct  than  in  the  adult.  It  is  gen- 
erally to  be  heard  at  the  fourth,  occasionally  at  the  fifth,  interspace 
until  the  fourth  year.  An  accurate  examination  of  the  valves  of 
the  heart  is  difficult,  particularly  in  early  childhood,  partly  from 


PHYSIOLOGY    OF    THE    INFANT    AND    CHILD. 


FIG   i.— DISSECTION  OF  A  NEW-BORN  INFANT,  SHOWING  THE  SIZE  AND  POSITION  OF  THE 

THYMUS  GLAND  AND  ITS  RELATION  TO  THE  LUNGS. 

A    Thyroid  gland.    B.  Thymus  gland.     C,  C.  Lungs.    D.  Esophagus.    E.  Stomach. 
Natural  size.    Dissection  made  by  Dr.  F.  S.  Ferris  from  a  case  in  his  own  practice. 


LUNGS.  2  5 

the  presence  of  the  thymus  and  partly  from  the  fact  of  the  high 
position  of  the  heart  in  the  chest  causing  confusion  of  the 
sounds  of  its  valves  with  those  of  respiration.  It  is  possible, 
also,  that  the  heart  may  change  its  position  with  the  move- 
ments of  the  body  to  a  greater  extent  in  childhood  than  in  later 
life. 

The  heart-beat  in  the  new-born  infant  varies  from  120  to  140 
pulsations  a  minute,  girls  having  a  slightly  more  rapid  heart 
action  than  boys.  According  to  McClellan,  the  pulse-rates  in 
subsequent  years  are  as  follows  : 

In  the  second  year,  100  to  115  beats  a  minute.  From  the 
seventh  to  the  fourteenth  year,  80  to  90  beats  a  minute,  and  after 
that,  75  to  80.  It  must  be  remembered,  however,  that  the 
normal  rate  and  the  rhythm  may  both  be  greatly  changed  by 
slight  causes. 

The  weight  of  the  heart  at  birth  is  about  20.5  gm.,  or  about 
two-thirds  of  an  ounce. 


LUNGS. 

The  apices  of  the  lungs  in  children  are  found  by  external  ex- 
amination to  occupy  almost  the  same  position  as  in  the  adult : 
that  is,  between  one  and  two  fingerbreadths  above  the  clavicle. 
The  vesicular  sounds  are  most  distinct  below  the  clavicle,  while 
the  bronchial  sounds  are  best  heard  in  the  upper  region  of  the 
sternum.  Owing  to  the  encroachment  of  the  liver  upon  the 
right  side  of  the  thorax,  a  considerable  difference  is  found  in  the 
size  of  the  spaces  occupied  by  the  right  and  the  left  lung,  the 
right  lung  extending  downward  as  low  as  the  eleventh  rib  poste- 
riorly, while  the  lower  border  of  the  left  lung  is  found  as  low  as 
the  twelfth  rib.  Anteriorly,  the  right  lung  extends  to  the  fourth 
or  fifth  rib,  while  the  lower  border  of  the  left  lung  is  found  at  the 
margin  of  the  sixth  rib.  The  bronchial  portion  of  the  respira- 
tory tract  is  much  more  highly  developed  than  the  vesicular 
during  early  infancy,  the  vesicular  portion  consisting  merely  of 
small  bud-like  dilatations  at  the  ends  of  the  lesser  bronchi.  The 
connective-tissue  element  is  also  found  in  greater  abundance  in 
infancy  than  in  later  childhood  or  in  adolescence.  The  blood- 
vessels of  the  lungs  are  more  distensible  and  tortuous  during 
early  childhood  than  in  later  life.  The  air  capacity  of  the  lungs 
is  smaller  proportionately  during  early  infancy  than  in  late  child- 
hood or  adult  life  ;  however,  we  find  this  increasing  rapidly  as 
age  advances.  According  to  Schnepf  and  Wintrich  (quoted  from 


26  PHYSIOLOGY    OF    THE    INFANT    AND    CHILD. 

Ashby  and  Wright),  the  vital  cubic  capacity  at  different  ages  is 
as  follows  : 

Three  to  four  years,  about 450  c.c 

Five  to  seven  years,  about goo  c.c 

Eight  to  ten  years,  about 1300  c.c 

Eleven  to  twelve  years,  about 1800  c.c 

Thirteen  to  fourteen  years,  about 2200  c.c 

In  adults  (average),  about 3300  c.c 

The  absorption  of  oxygen,  however,  is  relatively  greater  dur- 
ing childhood  than  in  adult  life,  while  the  expiration  of  carbonic 
acid  gas  is  somewhat  less.  In  new-born  infants  the  number  of 
respirations  varies  from  about  forty  to  forty-five  a  minute  ;  from 
this  number  they  slowly  decrease  until  the  third  or  fourth  year, 
when  they  number  about  from  twenty-five  to  thirty.  At  the  be- 
ginning of  adolescence,  or  about  the  fifteenth  or  sixteenth  year, 
they  average  twenty.  The  type  of  respiration  in  the  infant  is 
always  abdominal,  for  the  reason  that  during  early  life  the  dia- 
phragm is  the  largest  factor  in  the  production  of  respiration,  the  ribs 
moving  but  slightly  and  the  abdominal  muscles  aiding  but  little 
in  the  respiratory  movements.  Any  alteration  of  this  type  of 
respiration  is  nearly  always  a  symptom  of  disease  in  a  young 
child.  In  later  childhood,  however,  we  see  the  chest  participat- 
ing in  the  act  of  respiration,  the  ribs  being  raised  by  the  action 
of  the  other  respiratory  muscles  or  the  thoracic  muscles  of  res- 
piration. The  action  of  the  intercostal  muscles  is  of  slight  im- 
portance in  man.  As  has  been  pointed  out  by  Ebner  and  others, 
the  muscles  of  inspiration,  aside  from  the  diaphragm,  are  the 
quadratus  lumborum,  the  serratus  posticus  inferioris,  the  serratus 
posticus  superioris,  the  levatores,  the  scaleni,  etc.  The  inter- 
costal muscles  are  chiefly  of  importance  in  giving  rigidity  to  the 
chest.  As  the  child  approaches  puberty  we  see  the  type  of  res- 
piration varying  with  the  sexes,  the  abdominal  and  inferior  costal 
type  being  found  in  males  and  the  superior  costal  type  (so  called) 
in  females.  In  girls  there  is  much  less  movement  of  the  abdo- 
men, while  the  greater  amount  of  respiratory  movement  is  seen 
in  the  upper  part  of  the  thorax.  The  rhythm  of  respiration 
may  vary  considerably  in  children,  especially  in  the  very  young. 
It  may,  in  fact,  become  irregular  without  indicating  disease. 
The  costal  pleura  in  children  is  somewhat  thicker  than  in 
adults,  and  the  inferior  margin  of  the  pleura  may  extend  as  low 
as  the  articulation  of  the  twelfth  rib,  and  sometimes  even  as 
low  as  the  transverse  process  of  the  first  lumbar  vertebra  pos- 
teriorly. 


DIAPHRAGM THYMUS    GLAND THORAX.  2/ 

TM£  PACIFIC  CGlltGt  of  G,Tc 

DIAPHRAGM. 

The  diaphragm  occupies  a  higher  position  in  children  than  in 
adults,  and  is  proportionately  better  developed  on  account  of  its 
importance  as  an  organ  of  respiration.  In  regard  to  its  position, 
Rotch,  basing  his  opinion  largely  on  the  observations  which 
Dwight  made  upon  frozen  sections,  states  that  in  the  infant  the 
diaphragm  is  to  be  found  opposite  the  eighth  and  ninth  dorsal 
vertebrae.  On  the  right  side  it  rises  higher  than  on  the  left, 
arching  over  the  liver.  The  lowest  portion  is  that  extending 
along  the  central  or  median  line.  Anteriorly,  in  the  young 
child  it  is  said  to  be  inserted  somewhat  above  the  apex  of  the 
ensiform  cartilage. 

THYMUS  GLAND. 

This  structure  lies  in  the  anterior  mediastinum  immediately 
posterior  to  the  manubrium  of  the  sternum.  It  is  a  long,  flat- 
tened, lobulated  gland,  in  structure  resembling  the  salivary 
glands.  It  attains  its  greatest  development  about  the  second 
year  of  life,  after  which  time  it  disappears  rapidly.  In  color  it 
is  pinkish  gray,  and  its  weight  is  about  one-half  of  an  ounce.  It  is 
richly  supplied  with  blood-vessels.  Its  function  is  obscure  :  by 
some  it  is  supposed  to  aid  in  the  formation  of  the  red  blood- 
corpuscles.  The  undue  enlargement  of  this  gland  may  be 
accountable  for  some  cases  of  sudden  death  in  infants. 


THORAX. 

The  thorax  in  the  infant  and  young  child  is  of  much  less  con- 
sequence as  a  part  of  respiratory  mechanism  than  it  is  in  the 
adult.  During  early  life  it  is  somewhat  narrower  proportion- 
ately in  its  transverse  diameter  than  is  the  thorax  of  the  adult. 
The  average  anteroposterior  diameter  of  the  interior  of  the  adult 
thorax  bears  a  relation  to  the  transverse  of  i  to  2^  or  3.  In 
the  infant  at  birth  this  relation  bears  a  proportion  of  as  2  is  to  3 
(Rotch).  The  thorax  is  also  shorter  proportionately  from  above 
downward  in  the  infant  than  in  the  adult.  The  sternum  in  the 
young  child  is  placed  higher  than  in  the  adult,  the  top  of  the 
manubrium  being  on  a  level  with  the  first  dorsal  vertebra  in  the 
child,  while  in  the  adult  it  reaches  to  between  the  second  and 
third  vertebras.  In  children  with  rickets  the  manubrium  not 
infrequently  reaches  as  high  as  the  thyroid  cartilages,  as  in  a  case 
seen  in  Dr.  Taylor's  clinic.  The  shortness  of  the  neck  so  pro- 


28  PHYSIOLOGY    OF    THE    INFANT    AND    CHILD. 

duced  may  have  important  bearing  on  the  operation  of  trache- 
otomy and  other  surgical  procedures  about  the  neck.  The 
shape  of  the  sternum  during  early  childhood  is  said  to  approach 
more  nearly  that  of  the  female  than  the  male.  The  ribs,  too, 
are  more  nearly  horizontal,  and  form  a  larger  part  of  the  lateral 
walls  of  the  thorax  during  childhood  than  in  adult  life.  In 
quite  a  number  of  cases  a  certain  amount  of  variability  may  be 
found  in  the  development  of  the  thorax.  Especially  is  this  the 
case  in  the  measurement  of  the  two  sides,  the  circumference  of 
the  right  side  often  being  greater  than  that  of  the  left. 

The  ribs  of  the  child  are  flatter  and  more  elastic  than  are  those 
of  the  adult,  but,  owing  to  the  inferior  development  of  the  inspira- 
tory  muscles,  they  are  raised  but  slightly  during  respiration, 
unless  the  breathing  is  forced.  As  has  been  already  pointed  out, 
respiration  in  the  child  is  chiefly  accomplished  by  the  action  of 
the  diaphragm,  so  that  the  movement  of  the  thorax  is  compara- 
tively small.  The  bones  of  the  thorax  are  subject  to  various 
deformities,  caused  by  the  influence  of  disease.  Thus,  in  rickets 
we  may  have  a  formation  of  bony  protuberances  at  the  junction 
of  the  ribs  and  the  costal  cartilages,  or  from  extreme  softness  of 
the  structure  there  arises  a  narrowing  of  the  chest  with  a  pro- 
tuberance of  the  sternum,  causing  the  deformity  known  as 
pigeon-breast. 

ABDOMEN. 

The  abdomen  of  the  child  is  more  protuberant  and  is  of  a 
larger  size  relatively  than  that  of  the  adult,  owing,  chiefly,  to  the 
greater  size  of  the  liver  during  early  life.  This  organ,  as  has 
already  been  explained,  occupies  almost  the  entire  right  side  of 
the  abdomen,  and,  according  to  McClellan,  has  a  relative  weight 
to  the  whole  body  at  birth  of  about  I  to  8.  Its  lower  border, 
with  the  child  in  the  upright  posture,  reaches  nearly  to  the  crest 
of  the  ilium,  and  its  left  lobe  extends  across  to  the  costal  carti- 
lages of  the  left  lower  ribs.  In  the  middle  line  the  liver  is  in 
close  relation  to  the  skin  in  front  of  the  stomach,  and  reaches 
half  way  between  the  ensiform  cartilage  and  the  umbilicus.  Its 
lower  edge  corresponds  to  a  line  drawn  from  the  ninth  costal 
cartilage  on  the  right  side,  to  the  eighth  costal  cartilage  on  the  left. 

SPLEEN. 

In  the  child  the  spleen  can  be  outlined  externally  on  the  left 
side  in  the  neighborhood  of  the  tenth  and  eleventh  ribs,  at  which 
point  it  is  nearest  the  surface  of  the  body.  It  must  be  remem- 


PANCREAS KIDNEYS.  29 

bered  that  the  diaphragm  always  intervenes  between  the  abdom- 
inal wall  and  the  spleen  itself.  In  examining  the  organ  percus- 
sion may  prove  of  little  value,  as  a  distended  splenic  flexure  of 
the  colon  may  interfere  seriously  with  our  study.  Auscultatory 
percussion  will  here  render  efficient  service,  however,  and  when 
the  spleen  can  be  felt  beneath  the  costal  border,  we  may  safely 
say  it  is  enlarged.  The  size  of  the  spleen  is  said  to  vary  greatly, 
according  to  the  state  of  nutrition,  being  much  larger  in  well- 
nourished  children  than  in  those  affected  by  wasting  diseases. 
An  exception  to  this  will  appear  in  malnutrition  due  to  syphilis, 
in  which  case  the  spleen  is  frequently  enlarged.  The  size  of  the 
spleen  is  increased  during  and  after  digestion,  at  which  time  it 
contains  a  large  amount  of  blood.  It  is  covered  and  sustained 
by  the  peritoneum.  In  front  of  it  are  the  stomach  and  the  splenic 
flexure  of  the  colon.  When  enlarged,  it  is  said  that  the  spleen 
in  childhood  encroaches  more  upon  the  thoracic  cavity  than  in 
the  adult,  this  being  caused  by  the  greater  resistance  of  the 
costocolic  fold  of  the  peritoneum  upon  which  it  rests. 

PANCREAS. 

Although  the  pancreas  is  formed  about  the  second  month  of 
intra-uterine  life,  the  starch-digesting  (amylolytic)  action  of  the 
pancreatic  secretion  is  not  perfected  until  about  the  fourth  or  fifth 
month  after  birth.  The  fat-digesting  (proteolytic)  properties, 
however,  are  fairly  well  developed  at  birth.  This  has  an  im- 
portant bearing  on  the  question  of  the  proper  articles  of  food  to 
be  used  in  early  infancy. 

The  situation  of  the  pancreas  is  in  front  of  the  first  lumbar 
vertebra,  behind  the  stomach,  and  corresponds  with  a  point  about 
a  hand's  breadth  above  the  umbilicus. 


KIDNEYS. 

In  new-born  infants  and  young  children  the  kidneys  are  rela- 
tively larger  in  size  and  are  situated  lower  than  in  adults.  The 
latter  peculiarity  may  be  explained  when  we  know  that  the  lum- 
bar part  of  the  spine  is  relatively  small  at  birth.  The  kidneys 
lie  behind  the  peritoneum  in  a  considerable  quantity  of  fatty 
tissue,  which  helps  to  hold  them  in  position.  Owing  to  the  large 
size  of  the  liver,  the  right  kidney  is  situated  lower  than  the  left. 
The  kidney  in  children  is  more  tabulated  than  in  the  adult,  and 
the  suprarenal  capsules  are  much  larger — indeed,  in  young  in- 
fants they  sometimes  almost  cover  the  kidney. 


3O  PHYSIOLOGY    OF    THE    INFANT    AND    CHILD. 

During  the  first  year  or  two  of  life  the  kidneys  attain  nearly 
the  same  position  and  relations  as  in  the  adult. 

The  bladder  in  the  child  is  practically  an  abdominal  organ. 
When  distended,  it  occupies  nearly  the  whole  of  the  lower  por- 
tion of  the  abdomen,  and  this  is  an  important  fact  to  be  remem- 
bered in  making  an  examination  of  the  abdominal  organs  of  a 
child.  Before  such  an  examination  the  bladder  must  always  be 
emptied. 

The  shape  of  the  bladder  is  ovoid,  with  the  larger  end  resting 
in  the  pelvis.  As  the  pelvis  increases  in  size  the  bladder  becomes 
more  and  more  accommodated  within  its  cavity,  finally  becom- 
ing one  of  the  pelvic  organs.  In  the  child  the  peritoneum  is  re- 
flected entirely  over  the  posterior  surface  of  the  bladder,  and  ex- 
tends to  behind  the  urachus  downward  to  the  neck  of  the  bladder, 
and  thence  to  the  upper  part  of  the  rectum.  The  anterior  surface 
of  the  bladder  is  always  covered  by  peritoneum.  The  bladder 
is  capable  of  great  distention,  cases  have  been  reported  where 
the  summit  of  the  organ  has  reached  the  umbilicus,  and  even 
extended  to  the  ensiform  cartilage.*  The  prostatic  gland  is  very 
small  during  early  life. 

The  quantity  of  ttrine  secreted  increases  rapidly  for  the  first  five 
days  after  birth.  From  that  time  the  increase  is  slow.  The  average 
amount  excreted  by  a  child  of  four  or  five  days  is  about  twelve 
to  fifteen  ounces,  averaging  420  c.c.  At  two  years  of  age  the 
daily  excretion  will  average  fifteen  ounces,  or  500  c.c.,  and  at 
four  years  eighteen  to  twenty  ounces,  averaging  about  600  c.c. 
According  to  most  authorities,  the  urine  at  birth  is  more  con- 
centrated, and  therefore  of  a  higher  specific  gravity,  than  that 
secreted  after  the  infant  has  begun  to  feed  from  the  breast ;  it 
will,  however,  vary  considerably  with  the  amount  of  water  the 
child  is  allowed  to  drink.  As  a  rule,  however,  the  specific  gravity  is 
lower  in  infancy  and  early  childhood  than  in  adult  life.  It  may 
vary  from  1005  to  1010.  It  is  curious  to  note  that  in  the  kidneys  at 
birth  there  is  often  a  peculiar  reddish  discoloration  of  the  papilla, 
which  is  caused  by  the  presence  of  uric  acid  crystals  and  urates. 
It  would  seem  as  if  this  deposit  was  particularly  marked  in  those 
children  who  have  not  had  a  normal  supply  of  oxygen  at  birth. 
During  early  life  the  urine  may  be  turbid  and  dark,  but  later  it 
becomes  clear  and  of  a  light-yellow  color.  The  excretion  of 
urea  is  relatively  smaller  in  children,  and  the  same  is  also  true 
of  the  chlorids  and  phosphates.  Occasionally  traces  of  albumin 


*  In  a  case  reported  by  Dr.  J.  M.  Taylor  the  upper  surface  of  the  organ  reached 
as  high  as  the  diaphragm. 


STOMACH.  3 1 

may  be  found  in  the  urine  during  the  first  few  days  of  life,  but 
these  will  soon  disappear. 


STOMACH. 

The  stomach  is  placed  more  vertically  in  the  infant  than  in  the 
adult ;  in  fact,  its  axis  is  more  nearly  vertical  than  horizontal  or 
transverse.  Its  shape  at  birth  is  more  tubular  than  in  later  child- 
hood or  in  the  adult.  As  is  well  known,  the  cardiac  orifice  of 
the  fully  developed  adult  stomach  is  protected  by  a  valve  which 
prevents  the  regurgitation  of  fluids  into  the  esophagus.  In 
infants,  however,  this  valvular  constriction  is  deficient,  and  it  is 
owing  to  this  and  to  the  vertical  position  of  the  stomach  that 
regurgitation  of  fluids  so  much  more  frequently  occurs  in  infants. 
Indeed,  this  is  nature's  way  of  relieving  overdistention.  At 
about  the  middle  of  the  first  year  of  life  the  stomach  is  relatively 
broader  than  at  any  later  period ;  the  fundus  is,  at  this  time,  but 
slightly  developed.  The  capacity  of  the  stomach  at  birth  is  very 
small,  nearly  all  authorities  giving  it  as  being  less  than  one  ounce. 
The  size  and  capacity  of  the  organ  seem  to  vary  somewhat  with 
the  weight  of  the  child.  During  infancy  the  stomach  is  capable 
of  considerable  distention,  and  it  has  been  found  that  the  stomachs 
of  babies  fed  continuously  on  artificial  food  have  a  greater  capacity 
at  any  given  age  than  those  fed  by  the  breast.  On  the  other  hand, 
it  seems  probable  that  the  use  of  too  small  quantities  of  food 
has  a  tendency  to  cause  contraction  of  the  stomach,  thereby 
decreasing  its  capacity.  Following  birth  the  growth  of  the 
stomach  is  quite  rapid  for  the  first  three  months  of  life.  This 
is  followed  by  a  period  of  about  two  months  in  which  the 
increase  in  the  gastric  capacity  is  slight.  After  this  time,  how- 
ever, there  is  a  regular  and  steady  increase  in  size  until  adult  life 
is  attained. 

According  to  Rotch,  the  increase  of  gastric  capacity  is  as 
follows  : 

3  hours  old,  capacity  |-l  oz.     25-30  c.c. 


4  weeks  old, 

2>£  OZ. 

75 

8  weeks  old, 

3*     " 

96 

12  weeks  old, 

3l/3    " 

I  CO 

1  6  weeks  old, 

3ti  " 

107 

20  weeks  old, 

3f     " 

1  08 

An  accurate  study  of  the  capacity  of  the  stomach  of  infants  is 
of  great  practical  value  in  aiding  the  physician  to  regulate  the 
quantity  of  food  which  should  be  given.  As  the  experience  of 
those  interested  in  the  scientific  feeding  of  infants  increases,  the 


32  PHYSIOLOGY    OF    THE    INFANT    AND    CHILD. 

necessity  for  such  accurate  knowledge  becomes  of  more  and 
more  importance. 

As  an  organ  of  digestion,  the  stomach  does  not  play  so  im- 
portant a  part  in  infancy  as  in  adult  life.  This  is  said  to  be 
owing  partly  to  its  more  perpendicular  position  in  the  infant, 
and  also  to  the  fact  that  at  this  period  of  life  the  gastric  juice 
is  but  scantily  secreted.  When  milk  is  taken,  the  curd  is 
quickly  coagulated  by  the  rennet  ferment, — this  taking  from 
ten  to  fifteen  minutes,  —  after  which  it  is  acted  on  by  the 
pepsin  and  hydrochloric  acid,  but  before  digestion  is  complete 
a  large  portion  is  passed  into  the  intestine,  where  digestion 
is  completed.  According  to  Holt,  a  large  portion  of  the  milk 
passes  from  the  stomach  into  the  intestine  in  young  infants  dur- 
ing the  first  half  hour,  and  at  the  end  of*  an  hour  the  stomach 
is  empty. 

The  duration  of  gastric  digestion  varies  with  the  age  of  the 
infant  and  the  food  given  ;  as  a  rule,  human  milk  is  more  quickly 
digested  than  cow's  milk. 

The  gastric  juice  of  the  infant  contains  pepsin  and  hydro- 
chloric acid  as  in  the  adult,  and  lactic  acid  is  also  occasionally 
found,  but  all  these  elements,  and  especially  free  hydrochloric 
acid,  are  in  much  smaller  proportion  during  infancy,  and  it  is 
supposed  that  this  scanty  secretion  of  hydrochloric  acid  probably 
explains  the  feeble  germicidal  properties  of  the  gastric  juice  of 
infants  and  the  susceptibility  of  these  patients  to  gastro-enteric 
infection. 


SMALL  INTESTINE. 

The  average  length  of  the  small  intestine  in  the  infant  at  birth 
is  91^  feet.  According  to  Rotch's  measurement,  it  is  287  cm., 
although  he  states  that  he  has  seen  a  variation  of  61  cm.,  or 
about  two  feet.  During  the  first  month  of  life  this  increase  in 
length  is  about  the  same,  but  after  that  time  its  growth  is 
irregular.  During  childhood  the  upper  part  of  the  small  intes- 
tine usually  occupies  the  left  iliac  fossa,  while  the  lower  part  is 
found  in  the  iliac  fossa  of  the  right  side.  In  the  first  part  of  the 
duodenum  the  glands  of  Brunner  are  placed,  while  in  the  portion 
below  the  duodenum  the  patches  of  Peyer  can  be  found,  often  at 
a  very  early  period.  In  the  small  intestine  the  process  of  diges- 
tion is  continued  by  the  action  of  the  pancreatic  juice  and  other 
secretions.  The  fat  of  the  food  is  here  emulsified,  and  absorption 
of  elements  whose  digestion  was  begun  in  the  stomach  takes 
place. 


LARGE    INTESTINE CECUM.  33 


LARGE    INTESTINE. 

At  birth,  according  to  Treves,  the  large  intestine  measures 
about  one  foot,  ten  inches,  or  fifty-six  centimeters,  in  length. 
Rotch  states  that  there  is  very  little  variation  in  these  measure- 
ments— not  more,  in  his  experience,  than  five  inches,  or  12.7  cm. 
It  is  generally  taught  that  there  is  comparatively  little  increase 
in  length  in  the  first  three  or  four  months  of  life,  but  during  this 
time  the  whole  intestine  grows  more  rapidly  than  does  the  sig- 
moid  flexure,  which  at  birth  forms  about  one-half  the  entire 
length  of  the  large  intestine — indeed,  it  is  stated  that  the  sigmoid 
flexure  actually  diminishes  in  size  owing  to  a  readjustment  of  the 
mesentery  (McClellan).  Treves  states  that  at  the  end  of  the  first 
year  the  large  intestine  measures  two  feet,  six  inches,  or  76  cm. 
in  length  ;  at  six  years  about  three  feet,  or  91.5  cm.,  while  at  thir- 
teen years  its  length  will  be  three  feet,  six  inches,  or  107  cm. 
The  course  of  the  colon  is  from  the  right  iliac  fossa  upward  to 
the  liver,  from  which  point  the  bowel  passes  transversely  in  some- 
what of  an  arch  across  the  abdomen  to  the  spleen,  forming,  as  it 
curves,  the  hepatic  flexure,  the  splenic  flexure,  and  the  sigmoid 
flexure,  the  latter  curve  occurring  in  the  left  iliac  fossa.  Beyond 
this  point  it  terminates  in  the  rectum.  Not  infrequently  its 
course  may  lie  diagonally  across  the  abdomen,  from  the  hepatic 
region  to  the  left  groin.  In  children  the  transverse  colon,  when 
distended  with  gas  or  fecal  matter,  can  be  quite  clearly  outlined 
by  percussion. 

CECUM. 

The  cecum  occupies  a  higher  position  in  the  child  than  it  does 
in  the  adult,  and  is  also  somewhat  shorter  in  the  former  than  in 
the  latter.  In  thirty  out  of  thirty-five  cases  examined  by  Rotch 
the  position  of  the  cecum  varied  from  the  rightlumbar  region  to 
the  lower  part  of  the  right  iliac  fossa.  It  is  completely  invested 
by  peritoneum  except  on  its  posterior  surface.  As  to  whether  or 
not  the  peritoneum  covers  the  latter  site,  authorities  differ  ;  thus, 
Treves,  in  his  Hunterian  Lectures,  states  that  in  100  observations 
he  always  found  the  peritoneum  infolding  the  cecum  on  its  pos- 
terior surface,  and  Dwight  (quoted  by  Rotch)  found  that  out  of 
thirty-seven  young  children  the  cecum  was  completely  covered 
with  peritoneum  in  thirty-three  cases,  and  in  the  other  four  cases 
the  largest  part  of  the  posterior  surface  of  the  cecum  was  in- 
vested by  peritoneum.  It  is  stated  that  during  childhood  the 
cecum  is  much  more  movable  than  in  adult  life. 
3 


34  PHYSIOLOGY    OF   THE    INFANT    AND    CHILD. 


VERMIFORM  APPENDIX. 

The  position  of  the  vermiform  appendix  is  usually  behind  the 
cecum,  with  its  course  directed  upward  and  outward.  Externally, 
it  can  be  diagnosticated  in  case  of  operation  by  incising  in  the 
semilunar  line  upon  the  right  side,  at  a  point  midway  between  the 
umbilicus  and  ileum  (McClellan).  In  children  it  can  sometimes 
be  outlined  by  rectal  or  recto-abdominal  palpation  in  cases  where 
it  is  swollen.  Great  variation  in  the  length  and  course  of  the 
vermiform  appendix  is  frequently  seen.  It  may  be  wholly  or  par- 
tially covered  with  peritoneum,  the  length  of  the  attachments  of 
which  may  vary  considerably. 


SIGMOID  FLEXURE. 

The  sigmoid  flexure  consists  of  a  good-sized  loop  of  the  large 
intestine,  which  occupies  the  left  iliac  fossa,  although  it  is  occa- 
sionally found  in  the  pelvis  ;  the  mesenteric  attachment  here  is 
relatively  broad,  allowing  of  quite  a  considerable  amount  of 
movement.  The  point  at  which  the  sigmoid  flexure  of  the  colon 
becomes  the  rectum  is  of  interest  from  a  surgical  standpoint, 
because  it  is  at  this  point  that  stricture  of  the  colon  is  most  apt 
to  occur.  This  is  probably  due  to  the  arrangement  of  the  bands 
of  peritoneum,  the  so-called  sigmoid  mesocolon,  which  bind  the 
loops  of  bowel  so  closely  together  that  twisting  on  their  axes 
may  readily  occur. 

The  lower  portion  of  the  large  intestine,  known  as  the  rectum, 
is  straighter  in  childhood  than  during  adult  life.  This  is  due  in 
part  to  the  straightness  of  the  sacrum  at  this  time.  The  peri- 
toneum is  reflected  over  the  upper  portion  of  the  rectum  in  the 
same  manner  as  in  the  adult,  except  that  in  the  child  it  is  lower 
down  ;  the  attachments  between  the  rectum  and  the  surrounding 
parts  do  not  extend  so  high  in  children  as  in  adults. 


INTESTINAL  DISCHARGES. 

Following  birth,  the  first  discharge  from  the  intestines  is  of  a 
dark -brown  or  greenish-brown  color,  which,  from  its  resemblance 
to  the  inspissated  juice  of  the  poppy,  is  called  meconium.  This 
substance  is  odorless,  has  a  somewhat  acid  reaction,  and  is  com- 
posed of  partly  digested  amniotic  fluid,  cells,  cholesterin  crystals, 
and  sometimes  the  constituents  of  bile.  During  infancy,  while 
the  child  is  fed  on  a  milk  diet,  the  intestinal  discharges  are  of  a 


INTESTINAL    DISCHARGES.  35 

light-yellow  color  and  of  liquid  consistency,  containing  about 
85  per  cent,  of  water.  They  are  feebly  acid  in  reaction  and 
contain  fat,  traces  of  bilirubin,  mucus,  intestinal  epithelial  cells, 
lime  salts,  and  bacteria.  In  diseased  conditions  they  may  also 
contain  false  membrane,  pus,  blood,  parasites  and  their  ova,  or 
even  foreign  bodies.  The  amount  of  intestinal  discharge  during 
the  first  few  days  of  life  will  average  from  one  to  two  ounces, 
and  the  number  of  stools  varies  from  about  two  to  five  a  day. 
As  the  child  advances  in  age  the  number  of  bowel  movements 
become  gradually  fewer,  until  the  average  attains  about  that  of 
adult  life — namely,  one  or  two  in  twenty-four  hours.  In  color 
the  feces  do  not  change  in  health  until  the  child  begins  to  take 
starchy  food,  when  the  brown  color  appears.  The  bacteria  which 
are  found  in  the  intestinal  discharges  vary  in  number  and  species  ; 
many  varieties  have  not  yet  been  isolated ;  however,  the  proteus 
vulgaris,  the  bacillus  lactis  aerogenes,  and  Brieger's  bacillus  may 
any  or  all  be  found.  When  the  infant  begins  to  take  a  mixed 
diet,  various  forms  of  bacilli  appear,  among  them  the  streptococ- 
cus coli  gracilis  and  others.  The  color  of  the  fecal  discharges 
varies  slightly  in  health,  depending,  to  a  certain  extent,  upon 
the  character  of  the  food.  Certain  medicinal  agents,  espe- 
cially bismuth,  will  darken  the  color  of  the  bowel  movements. 
The  color  of  the  fecal  discharge  is  changed  greatly  in  disease ; 
thus  we  have  the  characteristic  clay-colored  discharges  seen  in 
certain  forms  of  intestinal  disease  or  in  pathologic  conditions 
wherein  the  bile  is  not  poured  into  the  intestinal  tract ;  the  green- 
colored  stool,  found  in  the  majority  of  forms  of  acute  intestinal 
inflections  of  moderate  severity  ;  and  the  peculiar  watery  dis- 
charge mixed  with  shreds  of  mucus — the  "rice-water"  passage 
of  acute  milk  infection. 

The  bowel  movements  may  be  increased  or  diminished  in  dis- 
ease. When  abnormally  large  and  frequent,  they  usually  indi- 
cate a  lack  of  capacity  of  the  intestine  to  absorb  nourishment;  this 
is  found  in  conditions  of  low  vitality.  When  the  lower  bowel 
is  chiefly  affected  and  nutrition  but  slightly  interfered  with,  the' 
movements  are  frequent  and  small. 

The  characteristic  odor  of  the  feces  is  changed  in  disease ; 
thus,  when  acid  fermentation  is  present,  they  have  a  sour  smell, 
or  when  decomposition  of  albuminoid  matter  has  occurred,  they 
are  putrid  or  highly  offensive.  Constant  feeding  on  broths  will, 
produce  the  same  result  from  the  same  cause.  The  musty 
odor  of  the  stools  of  cholera  infantum  is  well  known. 

Fragments  of  membrane  or,  rarely,  casts  of  the  intestine  are 
sometimes  found  in  the  stools  of  children  suffering  from  chronic 


36  PHYSIOLOGY    OF   THE    INFANT    AND    CHILD. 

(croupous)  enteritis.  Pus  is  seen  in  cases  of  severe  ulceration 
of  the  lower  bowel  and  in  bad  cases  of  chronic  enterocolitis. 
Blood  in  the  stools  may  be  the  sign  of  the  presence  of  an  ulcer 
of  the  rectum  or  fissure  of  the  anus  ;  it  is  also  seen  in  severe 
inflammation,  especially  of  the  lower  bowel,  and  in  intussuscep- 
tion. It  is  not  infrequently  seen  in  hemophilia.  Dark  or  partly 
digested  blood  may  be  seen  in  the  stools  when  the  child  has 
sucked  from  a  fissured  nipple  ;  it  is  also  a  symptom  of  many 
other  conditions,  such  as  congenital  malformation  of  the  bile- 
ducts  and  diseased  conditions  of  the  liver. 

Melena  in  the  new-born  is  usually  accompanied  by  hemor- 
rhages from  the  bowels  (see  description  of  this  disease). 

Intestinal  parasites  and  their  ova  and  foreign  bodies  are  fre- 
quently found  in  the  feces  of  children. 

THE  HEAD. 

The  average  circumference  of  the  head  at  birth,  the  measure- 
ment being  taken  on  a  level  with  the  middle  of  the  forehead  in 
front  and  the  occipital  protuberance  behind,  is  about  thirteen  to 
fifteen  inches,  or  thirty-four  to  thirty-seven  centimeters.  The 
longest  diameter  measures  at  birth  about  1 1.2  inches. 

These  measurements  will,  as  has  been  before  stated,  bear  a 
certain  amount  of  relation  to  the  measurement  of  the  thorax 
and  abdomen,  and  also  to  the  entire  length  of  the  child  at  term. 
The  shape  and  contour  of  the  head  and  general  topographic 
anatomy  differ  widely  from  that  of  the  adult ;  thus  we  see  that 
the  cranial  bones  during  early  life  are  softer  and  capable  of  much 
greater  compression  than  at  a  later  period  of  development. 
Between  the  two  divisions  of  the  frontal  bones  anteriorly,  and 
also  between  the  superior  borders  of  the  parietal  bones  poste- 
riorly, we  find  an  opening  caused  by  the  lack  of  osseous  deposit 
in  the  bones  which  form  the  boundaries  of  the  space.  This 
space  is  covered  by  skin  and  periosteum,  and  is  known  as  the 
"  anterior  fontanel."  The  situation  of  this  space  usually  corre- 
sponds with  the  junction  of  the  sagittal  and  coronal  sutures. 
Posteriorly,  at  the  junction  of  the  sagittal  and  lambdoidal  sutures, 
is  a  smaller  fontanel,  known  as  the  "  posterior  fontanel."  The 
posterior  fontanel  usually  closes  soon  after  birth,  the  anterior 
one  remaining  open  until  about  the  end  of  the  second  year,  or, 
more  accurately,  at  about  the  twentieth  month.  The  size  of  the 
anterior  fontanel  at  birth  is  about  I  ^  by  I  %'  inches  (4  by  3 
cm.).  According  to  some  authorities,  the  anterior  fontanel 
increases  in  size  from  birth  up  to  about  the  ninth  month,  after 


THE    HEAD.  37 

which  it  slowly  grows  smaller.  Occasionally  supernumerary 
bones,  called  Wormian  bones,  which  may  vary  considerably  in 
number  and  size,  are  found  in  the  sutures  between  the  bones  of 
the  skull  or  sometimes  within  the  fontanels.  Their  most  fre- 
quent site  is  in  the  course  of  the  lambdoid  suture  or  in  the  poste- 
rior fontanel  ;  they  are  rarely  found  in  the  anterior  fontanel. 
The  level  of  the  scalp  covering  the  fontanels  is  usually  about 
the  same  or  very  slightly  below  that  covering  the  skull  gener- 
ally ;  this,  however,  is  greatly  modified  in  disease.  The  pulsa- 
tions of  the  cranial  circulation  can  be  distinctly  felt  at  the  ante- 
rior fontanel.  The  relation  which  the  size  of  the  face  bears  to 
that  of  the  cranium  is  vastly  different  in  the  infant  from  that 
which  we  see  in  adult  life.  In  the  infant  and  during  early  life 
the  face  is  much  smaller  in  proportion  to  the  size  of  the  cranium 
than  later.  According  to  Froriep,  the  proportion  between  the 
size  of  the  face  and  that  of  the  cranium  at  birth  is  as  i  to  8, 
while  in  the  adult  it  is  as  I  to  2.  While  the  height  of  the  orbit 
bears  nearly  the  same  proportion  to  that  of  the  skull  during 
infancy  that  it  does  in  adult  life,  the  combined  spaces  of  the  two 
orbits  equal  nearly  half  the  size  of  the  face  in  infancy,  while  in  the 
adult  they  equal  slightly  less  than  one-third.  The  lower  border 
of  the  nasal  opening  during  infancy  is  a  little  below  the  lowest 
point  of  the  orbit,  while  in  the  adult  it  is  very  much  below.  The 
breadth  of  the  skull,  measured  between  the  most  distant  parts 
of  the  zygomatic  arches,  bears  a  relation  to  the  height  of  the 
face  of  about  the  proportion  as  10  is  to  4,  this  proportion  being 
much  smaller  in  the  adult.  In  infancy  the  lower  jaw  is  nearly  on 
the  same  plane  as  the  mastoid  process  of  the  temporal  bone,  and 
the  upper  border  of  the  zygoma  is  on  a  level  with  the  floor  of 
the  nasal  cavity.  In  the  adult  the  upper  border  of  the  zygoma 
is  at  or  near  the  level  of  the  floor  of  the  orbit  (Rotch).  The 
gums  of  the  new-born  infant  do  not  meet.  A  lateral  aspect  of 
the  skull  of  the  new-born  will  show  that  the  auditory  meatus  is 
situated  at  a  point  about  the  center  of  a  line  drawn  along  its 
inferior  margin,  while  in  the  adult  it  is  decidedly  posterior  to  the 
center  of  this  line.  In  infants  and  children  the  skin  of  the  scalp 
is  thicker  than  that  of  any  other  part  of  the  body,  and  is  closely 
adherent  to  the  aponeurosis  of  the  occipitofrontalis  muscle.  The 
pericranium  is  but  lightly  attached  to  the  bones  of  the  skull, 
being  intimately  blended  at  the  sutures  with  the  membrane 
between  the  soft  bones  of  the  child's  head  ;  it  is  lax  and  admits 
of  extravasations  of  blood  beneath  it,  producing  what  is  known 
as  cephalhematoma. 

The  relation  between  the  development  of  the  head  and  thorax 


38  PHYSIOLOGY    OF    THE    INFANT    AND    CHILD. 

is  exceedingly  interesting.  The  circumference  of  the  head,  which 
is  thirty-seven  centimeters,  or  fifteen  inches,  exceeds  that  of  the 
thorax,  the  latter  being  thirty-five  centimeters,  or  fourteen  inches. 
In  the  majority  of  cases  this  excess  in  the  size  of  the  head 
continues  throughout  the  entire  first  year.  During  this  time, 
however,  the  thorax  increases  in  size  at  a  more  rapid  rate  pro- 
portionately than  does  the  head,  until,  at  the  beginning  of  the 
second  year,  we  find  the  circumference  of  the  thorax  slightly  in 
excess  of  that  of  the  head,  and  from  this  time  on  the  thoracic 
circumference  continues  greater  than  the  cranial. 

TABLE    SHOWING    PROPORTIONATE    SIZES    OF    THE   HEAD    AND 

THORAX   FROM  BIRTH  TO  THE  THIRTEENTH  YEAR.— (Rotch.} 

(The  Subjects  of  these  Observations  were  Male  Children.) 


AGE. 

HEAD. 

THORAX. 

At  birth, 

37      cm.    (15      inches). 

35  cm.  (14      inches). 

2  years, 

48 

(19 

)• 

51 

(20/s 

)• 

3 

51 

(20>g 

). 

55 

(21% 

)• 

4 

53 

(21 

). 

54 

(21% 

)• 

5 

53 

(21 

)• 

54 

(21% 

)• 

6 

52 

(20)4 

). 

55 

(21% 

7 

54 

fax 

. 

54 

(21% 

£ 

8 

53 

(21 

). 

59 

(23/S 

). 

9 

54 

fax 

). 

61 

(24 

). 

10 

53 

(21 

). 

62 

(24/2 

ii 

56 

(22/S 

). 

63 

(24^ 

(! 

12 

53-5 

fan 

). 

63 

(24  tf 

')• 

13 

54 

(**X 

)• 

66 

(26 

)• 

BRAIN. 

At  birth  the  dura  mater  is  closely  adherent  to  the  skull  ;  in 
fact,  so  intimately  are  they  connected  that  extravasations  can  not 
take  place  between  them.  In  the  subarachnoid  space  a  larger 
amount  of  fluid  is  found  during  infancy  and  throughout  child- 
hood than  in  adult  life  ;  the  quantity  of  fluid  present  is  generally 
just  about  sufficient  to  fill  the  space  comfortably.  McClellan 
(quoting  from  Hilton)  states  that  hydrocephalus,  due  to  an  exces- 
sive amount  of  fluid  in  the  ventricles  of  the  brain,  may  be  caused 
by  a  closure  of  a  small  opening  in  the  pia  mater,  which  is  found 
at  the  inferior  boundary  of  the  fourth  ventricle,  and  which  is 
known  as  the  foramen  Magendie.  The  blood-vessels  of  the  pia 
mater  are  so  exceedingly  delicate  that  high  blood  pressure,  trau- 
matisms,  etc.,  may  readily  cause  hemorrhage  into  the  subarach- 


SIGHT.  39 

noid  space  ;  and  from  this  cause  monoplegia,  hemiplegia,  or 
diplegia  may  result.  During  fetal  life  and,  indeed,  from  birth 
up  to  the  seventh  year  the  growth  and  development  of  the  brain 
are  very  rapid,  but  after  the  seventh  year  the  growth,  although 
steady,  is  slow.  Cellular  multiplication  in  the  cortex  of  the  brain 
ceases  at  the  third  month  of  fetal  life.  At  birth  the  weight  of 
the  brain  is  one-third  that  of  the  adult  encephalon.  At  the 
seventh  or  eighth  year  the  adult  size  and  weight  are  practically 
attained,  though  there  may  be  a  slight  increase  in  both  up  to 
the  twenty-fifth  year.  This  rapid  attainment  of  weight  is  due 
to  the  relatively  greater  amount  of  medullary  matter  in  the 
child's  brain  ;  subsequent  growth  is  represented  by  an  increase 
in  the  thickness  of  the  cortex  and  in  the  size  of  the  cortical 
constituents,  as  has  been  pointed  out  by  Boyd,  Veirordt,  and 
Bischoff.  At  birth  the  brains  of  male  and  female  children  are 
practically  the  same  size,  but  subsequently  the  brain  of  the  male 
grows  much  more  rapidly  than  does  that  of  the  female. 

One  of  the  most  important  points  of  external  difference  be- 
tween the  brains  of  the  child  and  the  adult  is  that  the  fissure  of 
Sylvius,  in  its  relation  to  the  sphenoparietal  and  squamous 
sutures,  occupies  a  higher  position  in  childhood  than  in  later 
life.  Both  Symington  and  McClellan  found,  in  a  large  number 
of  examinations  and  dissections  of  frozen  sections  of  the  brains 
of  children  of  various  ages  under  seven  years,  that  the  Sylvian 
fissure  was  always  above  the  squamous  suture  and  was  covered 
by  the  parietal  bone.  The  position  of  the  fissure  of  Rolando  is 
about  the  same  in  the  child  as  in  the  adult.  According  to 
Huschker,  the  cerebellum  is  much  smaller,  as  compared  to  the 
cerebrum,  at  birth  than  later  in  life.  The  convolutions  of  the 
brain  in  the  infant  are  slightly  more  shallow  and  have  a  much 
less  complex  arrangement  than  in  the  adult.  The  depressions 
or  sulci  between  the  convolutions  are  not  so  deep  in  early  as  in 
later  life.  The  highly  specialized  centers  of  the  brain  are  ap- 
parently not  fully  developed  in  the  young  infant. 

SIGHT. 

From  an  anatomic  standpoint,  the  eye  is  fully  developed  at 
birth  and  is  sensitive  to  light.  There  is  no  capacity,  however,  to 
interpret  the  images  received  by  it.  Apparently,  the  infant  can 
distinguish  light  from  darkness  at  a  very  early  age,  and  shows 
pleasure  in  looking  at  a  light  or  a  bright  object.  About  the 
third  month  a  baby  will  usually  begin  to  know  its  mother  or 
nurse,  and  by  the  sixth  month  many  objects  with  which  the 


4O  PHYSIOLOGY    OF    THE    INFANT    AND    CHILD. 

child  is  in  constant  association  can  be  recognized.  The  power  to 
estimate  distance  and  to  coordinate  movements  by  sight  is  not 
developed  until  some  time  later.  It  is  said  that  an  infant  can  not 
appreciate  color  until  after  one  year  of  age.  Red  and  yel- 
low are  often  the  earliest  colors  recognized.  According  to 
Preyer,  the  movements  of  the  eyes  are  not  coordinated  during 
early  infancy. 

HEARING. 

Apparently  the  sensation  of  hearing  is  not  fully  developed  at 
birth.  It  has  been  stated  that  this  is  possibly  due  to  the  absence 
of  air  from  the  tympanum  and  to  a  swollen  condition  of  its 
mucous  membrane.  An  infant  should  be  able  to  hear  a  loud 
sound  by  the  end  of  the  second  week.  Failure  to  hear  sounds 
as  late  as  the  fourth  or  fifth  week  may  show  that  the  child  is 
deaf  or  idiotic.  The  power  to  appreciate  the  direction  of  familiar 
sounds  appears  about  the  third  month.  The  senses  of  touch,  taste, 
and  smell  are  probably  quite  well  developed  at  birth.  Sensibility 
to  touch,  temperature,  and  pain  is  probably  not  very  acute  in 
early  infancy. 

LACRIMAL  GLANDS. 

At  birth  the  lacrimal  glands  are  not  fully  developed.  It  is 
rarely  that  a  baby  sheds  tears  before  the  third  or  fourth  month. 
When  an  infant  is  seriously  ill  no  tears  are  shed,  and  their  ap- 
pearance is  said  to  be  a  sign  of  beginning  improvement. 


SALIVARY  GLANDS. 

The  secretion  of  saliva  is  not  fully  established  in  the  new- 
born infant,  and  in  consequence  of  this  we  find  the  mucous  mem- 
brane of  the  mouth  quite  dry.  The  starch-digesting  function  of 
the  saliva  is  very  slightly  present,  if  present  at  all,  at  birth. 


THE  SWEAT-GLANDS. 

Young  infants  rarely  perspire  to  any  marked  degree  except 
when  overheated,  although  the  skin  may  be  very  slightly  moist, 
especially  during  sleep.  Profuse  and  continued  perspiration  is 
usually  a  symptom  of  rickets,  and  this  is  particularly  the  case 
when  the  sweating  is  greatest  about  the  head  and  increases 
during  the  night. 


GENERAL    SYMPTOMATOLOGY    AND    DIAGNOSIS.  4! 


SEBACEOUS  GLANDS. 

As  evidence  that  these  glands  are  capable  of  performing  their 
function  before  birth  we  have  the  vernix  caseosa  covering  the 
body  of  the  new-born  child.  The  scalp  of  the  infant  may  later 
become  covered  with  a  yellowish,  scaly  secretion  known  as 
seborrhoea  capitis. 

THE  TESTICLES. 

Under  normal  conditions  the  testicles  descend  through  the 
inguinal  canal  into  the  scrotum  during  the  ninth  month  of  intra- 
uterine  life.  It  is  not  uncommon,  however,  to  see  children  in 
whom  one  or  both  testicles  are  still  in  the  abdominal  cavity,  and 
some  of  these  patients  will  need  surgical  care.  If  the  descent  of 
the  testicles  is  greatly  delayed,  a  portion  of  intestine  may  follow 
its  descent  down  through  the  canal  into  the  scrotum. 


THE  BREASTS. 

The  breasts  of  infants  of  both  sexes  may  be  somewhat  en- 
larged at  birth,  and  may  contain  a  milky  secretion  which,  under 
the  microscope,  resembles  colostrum.  Should  this  secretion  be- 
come so  increased  in  quantity  as  to  cause  great  distention  of  the 
breasts  and  pain,  the  milk  should  be  pressed  out  by  gentle  mas- 
sage and  a  small  breast-binder  applied.  Great  care  should  be 
exercised  to  keep  the  nipples  aseptically  clean  or  an  abscess  may 
follow.  The  condition  usually  disappears  toward  the  end  of  the 
first  month. 


GENERAL    SYMPTOMATOLOGY  AND    DIAGNOSIS 
OF  DISEASE    IN    CHILDREN. 

In  the  examination  of  children,  especially  those  too  young 
to  talk  intelligently,  a  method  differing  from  that  used  in  adults 
must  be  employed.  The  young  child  can,  of  course,  tell  us 
nothing ;  so  that  we  must  rely  on  the  mother  or  nurse  for  a 
history  of  the  case,  and  it  is  always  well  to  allow  the  mother 
to  give  the  history  of  the  child's  illness  in  her  own  words  before 
questioning  her.  During  the  recital  of  these  symptoms  we  may 
closely  observe  the  patient  for  any  symptoms  which  may  aid  in 
the  diagnosis  of  the  case.  In  the  first  place,  a  careful  history  of 


42  PHYSIOLOGY    OF    THE    INFANT    AND    CHILD. 

the  little  patient  must  be  elicited.  As  disorders  of  nutrition  play 
so  important  a  part  in  the  diseases  of  childhood  and  produce 
symptoms  which  are  often  not  only  severe,  but  also  very  obscure, 
we  should  obtain  all  the  details  of  the  character,  amount,  and 
preparation  of  its  food,  together  with  the  frequency  of  feeding 
and  any  changes,  and  their  effects  on  the  child.  The  condition 
of  the  appetite  should  be  noted  ;  whether  the  child  is  comfort- 
able after  meals  or  whether  it  vomits  or  suffers  pain.  Carefully 
ascertain  the  condition  of  the  bowels  through  the  frequency, 
color,  and  character  of  the  movements.  This  is  so  important 
that  the  physician  should  make  this  examination  personally. 
The  frequency  of  micturition  should  be  ascertained  and  a  chemic 
and  microscopic  examination  of  the  urine  should  be  made. 

Inquire  into  the  time  of  dentition  and  the  condition  of  the  child 
during  this  period,  whether  the  dentition  was  abnormal  or  diffi- 
cult;  search  after  all  the  symptoms  which  manifested  themselves. 

All  facts  relating  to  the  growth  and  development  of  the  patient 
are  of  importance — thus  :  the  condition  of  the  child  at  birth,  its 
subsequent  growth,  at  what  age  it  was  able  to  stand,  walk,  and 
talk.  All  previous  diseases,  especially  the  infective  fevers,  should 
be  noted,  and  whether  or  not  the  child  is  now  suffering  from  any 
of  the  sequelae  of  these  diseases. 

In  obtaining  the  history  of  the  present  illness,  learn  the  exact 
character  of  its  onset,  time  of  duration,  the  presence  or  absence  of 
fever,  restlessness,  or  pain,  with  its  character.  The  position  which 
the  child  assumes  when  asleep  or  awake,  its  cry,  the  interest  it  takes 
in  its  surroundings,  together  with  all  the  special  symptoms,  are  of 
the  utmost  diagnostic  importance.  When  the  illness  has  lasted 
some  time  or  has  become  actually  chronic,  always  inquire  into  the 
history  of  both  father  and  mother — for  a  history  of  syphilis,  tuber- 
culosis, or  other  diseases  which  may  be  inherited.  Examine 
the  other  children  of  the  family  if  there  be  any.  The  character 
of  the  mother's  labors,  especially  that  by  which  the  child  under 
consideration  was  born,  is  important. 

Posture  and  General  Expression  of  a  Child  in  Health  and  Dis- 
ease.— The  posture  assumed  by  an  infant  or  young  child  is  often 
quite  significant  of  its  condition.  Before  the  age  at  which  a 
healthy  infant  is  able  to  sit  up  it  will  lie  quietly  or  move  its  limbs 
in  the  same  manner  as  during  intra-uterine  life.  Except  when 
hungry  or  when  its  napkins  require  changing  it  seldom  cries. 
When  asleep,  it  may  occasionally  lie  on  its  back,  although  the 
usual  position  is  on  one  or  the  other  side,  with  its  thighs,  legs,  and 
arms  somewhat  flexed.  Not  infrequently  an  infant  may  assume 
a  semiprone  position.  Healthy  infants  invariably  sleep  with  the 


GENERAL   SYMPTOMATOLOGY    AND    DIAGNOSIS.  43 

mouth  closed,  breathing  through  the  nose.  The  breathing  is 
regular,  gentle,  and  accompanied  by  little  if  any  play  of  the 
alae  of  the  nose. 

The  most  common  cause  of  disturbed  sleep  in  an  infant  under 
four  months  of  age  is  indigestion,  although  as  the  period  of 
dentition  approaches  disturbed  sleep  may  be  a  symptom  of  the 
onset  of  this  condition.  Syphilitic  or  rachitic  infants,  as  a  rule, 
sleep  poorly.  Continued  restlessness  for  a  number  of  nights 
may  mean  that  the  child  is  undergoing  an  unusually  severe 
dentition,  etc.,  if  it  occurs  at  this  period  of  its  life.  Dentition 
may  even  cause  a  slight  rise  of  temperature,  but  this  symptom 
should  always  excite  suspicion,  as  many  of  the  more  serious  dis- 
eases present  such  a  beginning.  Difficulty  in  falling  asleep  often 
results  from  heavy  suppers.  When  the  child  starts  up  and 
screams  after  having  fallen  asleep,  it  probably  has  night-terrors 
or  is  suffering  from  the  results  of  some  fright  or  nervous  excite- 
ment which  has  occurred  during  the  previous  day.  The  child 
with  meningitis  also  screams  during  sleep,  but  its  general  con- 
dition and  history,  with  the  fact  that  patients  with  meningitis 
as  usually  seen  are  in  a  state  of  semicoma  rather  than  sleep, 
will  help  to  distinguish  the  disease. 

When  a  child  otherwise  healthy  sleeps  continuously  with  its 
mouth  open,  it  is  a  symptom  of  the  presence  of  enlarged  tonsils 
or  adenoids  in  the  nasal  canal.  The  sleep  of  a  hungry  infant 
is  disturbed,  the  child  waking  frequently  and  making  sucking 
movements  with  the  lips.  The  same  condition,  however,  may 
occasionally  be  seen  in  some  forms  of  indigestion. 

There  are  three  classes  of  diseases  seen  in  children  which  have 
a  more  or  less  typical  posture  and  expression  of  the  face ;  these 
are  affections  of  the  gastro-intestinal  tract,  the  respiratory  system, 
and  of  the  brain.  Each  class  is  distinguished  more  or  less  by 
its  characteristic  posture,  expression,  and  general  appearance, 
although  great  variations  are  often  seen.  In  diseases  of  the 
gastro-intestinal  tract  the  child  is  restless,  crying,  and  peevish. 
The  cry  resembles  that  of  hunger,  but  is  kept  up,  excepting  for 
a  few  moments  after  taking  food ;  there  is  rapid  emaciation, 
especially  of  the  lower  part  of  the  face  and  extremities,  with 
depression  of  the  fontanels.  The  condition  continuing,  the  face 
soon  assumes  the  "  hatchet  type."  The  eyes  are  sunken  and 
staring,  with  deep  hollows  surrounding  them,  due  to  the  ab- 
sorption of  orbital  fat  and  probably  also  to  muscular  relaxation. 
The  entire  body  gives  an  impression  of  limpness  and  loss  of 
tone.  The  expression  of  the  mouth  is  one  of  disgust,  and 
around  it,  in  chronic  cases,  is  frequently  seen  a  blue  line. 


44  PHYSIOLOGY    OF    THE    INFANT    AND    CHILD. 

In  diseases  of  the  respiratory  system,  of  which  we  may  con- 
sider bronchopneumonia  a  type,  the  child's  face  is  flushed,  the 
eyes  are  bright,  but  the  facial  expression  is  dull,  anxious,  and 
full  of  pain.  While  nursing  the  child  drops  the  nipple  fre- 
quently to  breathe,  attempts  to  cry,  but  catches  its  breath,  sup- 
pressing its  cry  because  of  pain,  and  coughs  with  a  short,  catchy, 
grunting  cough.  The  cry  is  short,  hoarse,  suppressed,  and 
intermixed  with  coughing.  The  breathing  is  rapid,  more  or  less 
labored,  the  alae  of  the  nose  dilating  widely  while  the  angles  of 
the  mouth  are  lowered  and  the  lips  parted  so  as  to  admit  as  much 
air  as  possible.  When  much  dyspnea  is  present,  there  is  reces- 
sion of  the  supraclavicular  and  suprasternal  regions,  with  sinking 
of  the  intercostal  spaces  and,  in  extreme  cases,  lateral  contraction 
of  the  chest-walls.  The  skin  is  hot  and  dry  and  may  be  pale, 
reddish,  or  somewhat  bluish  if  cyanosis  exists.  The  patient  is 
restless,  tosses  about,  and  assumes  those  positions  which  favor 
the  ingress  of  air  into  the  lungs. 

Adenoids  and  diseases  of  the  tonsils  generally  cause  the  face 
to  assume  a  dull  expression,  sometimes  almost  vacant.  The 
mouth  is  constantly  open.  The  child  suffers  from  a  persistent 
running  of  the  nose.  During  sleep  these  children  generally  lie 
with  the  mouth  open — are  "mouth-breathers" — and  snore  a 
great  deal. 

Diseases  of  the  brain,  of  which  acute  meningitis  is  a  type, 
present  a  different  picture.  The  body  is  usually  more  or  less 
rigid — may  even  be  in  a  state  of  opisthotonos.  There  is  usually, 
at  least,  some  retraction  of  the  head.  In  the  later  stages  there 
may  be  general  relaxation  with  complete  coma.  The  facial  ex- 
pression is  characteristic  :  the  eyes  are  closed,  the  brows  are 
knitted,  and  the  muscles  of  the  jaw  are  contracted.  The  gen- 
eral aspect  of  the  upper  half  of  the  face  has  been  described  as 
giving  the  appearance  of  deep  thought,  while  the  tightly  closed 
jaw  and  retracted  head  would  give  the  appearance  of  stern  de- 
termination. The  body  is  much  emaciated,  the  fontanels  are  full 
and  bulging,  and  the  eyes  may  be  closed,  but  more  frequently 
they  are  unequally  open.  The  pupils  are  irregular,  and  there 
may  be  strabismus  or  nystagmus.  The  cry  is  a  short,  sharp 
shriek  and  is  mostly  nocturnal  ;  it  is  almost  characteristic  of 
meningitis  ;  the  only  cry  resembling  it  is  that  of  chronic  bone 
disease.  The  skin  is  generally  hyperesthetic,  and  not  infre- 
quently there  is  a  tendency  to  spasms  when  touched.  The 
general  hyperesthesia  of  this  condition  is  to  be  distinguished 
from  the  local  soreness  of  scurvy,  rheumatism,  and  disease  of 
the  joints. 


CHAPTER  II. 

DISEASES  OCCURRING  AT  OR  NEAR  BIRTH. 


ASPHYXIA  NEONATORUM. 

Synonyms. — APPARENT  DEATH  OF  THE  NEW-BORN  ;    ASPHYXIE  DES 
NOUVEAU  NES  ;  ASPHYXIA  PALLIDA  NEUROSA. 

Definition. — Deficient  oxygenation  of  the  fetal  blood. 

Causes. — Asphyxia  in  the  new-born  may  be  divided  into  (i) 
antepartum,  or  mtra-uterine,  asphyxia  and  (2)  postpartum,  or 
asphyxia  occurring  immediately  after  birth.  The  causes  of  ante- 
partum asphyxia  are :  Partial  or  complete  detachment  of  the 
placenta;  interference  with  placental  circulation,  such  as  would 
be  caused  by  pressure  on  the  umbilical  cord,  or  by  the  cord  be- 
ing drawn  tightly  about  the  child's  body  or  neck  ;  considerable 
nervous  depression  in  the  mother ;  loss  of  blood ;  continued 
depression  of  the  fetal  skull  by  the  maternal  parts  ;  premature 
attempt  at  respiration  by  the  fetus  and  consequent  inspiration 
of  the  amniotic  fluid  or  the  secretions  of  the  birth  canal.  If 
attempts  at  respiration  during  the  child's  passage  along  the  birth 
canal  are  vigorous  and  prolonged,  there  may  result  a  form  of 
catarrhal  pneumonia,  known  as  "  inspiration  pneumonia,"  which 
may  come  on  a  few  hours  after  birth  and  will  probably  prove 
fatal. 

Postpartum  and  Extra-uterine  Causes. — The  most  common 
cause  of  asphyxia  following  birth  is  imperfect  development  of 
the  child.  This  may  arise  from  the  fact  that  the  fetus  is  imma- 
ture, the  respiratory  function  on  this  account  being  so  feeble  that 
it  can  not  freely  inspire  air  in  sufficient  amount  to  inflate  the 
lungs,  thus  leaving  areas  of  pulmonary  vesicles  in  an  unexpanded 
condition. 

This  condition  of  deficient  pulmonary  expansion  is  known  as 
atelectasis.  The  bony  walls  of  the  thorax  may  be  too  soft  to 
allow  of  expansion  through  muscular  action.  Simple  weakness 
alone  in  the  child  may  be  a  cause  of  asphyxia  following  birth. 

45 


46  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

Disease  affecting,  by  mechanical  pressure,  the  respiratory 
apparatus,  or  structural  changes  in  the  latter,  may  be  causes. 
We  may  also  see  asphyxia  arising  from  syphilitic  disease  of  the 
liver  or  lungs  or  from  pressure  produced  by  dropsy  or  tumors. 

Asphyxia  following  prolonged  birth  pressure  may  be  caused 
by  hemorrhage  into  the  fourth  ventricle  or  into  the  substance  of 
the  medulla,  thus  producing  pressure  on  the  respiratory  centers. 
In  other  cases  we  may  see  hemorrhages  into  the  lungs  them- 
selves, producing  postpartum  asphyxia. 

Asphyxia  of  the  new-born  may  be  divided  into  three  grades  : 

1.  A  slight  suspension  of  respiration,  due  to  an  accumulation 
of  mucus  or  a  foreign  body  in  any  part  of  the  respiratory  tract. 

2.  There  may  be  observed  a  type  of  asphyxia  known  as  the 
livid,  sthenic,  or  apoplectic  form,  seen  in  robust  and  full-blooded 
infants. 

3.  A  condition  in  which  the  child  is  pale,  limp,  and  apparently 
lifeless,  and  which  is  known  as  pallid,  asthenic,  or  anemic  as- 
phyxia. 

Pathology. — Postmortem  examination  will  reveal  patches  of 
extravasation  and  ecchymoses  in  various  organs,  particularly  the 
brain,  meninges,  and  liver.  The  lungs  are  dark  in  color,  firmer 
than  normal,  and  engorged  with  blood.  The  air-passages  are 
more  or  less  filled  with  mucus,  amniotic  fluid,  and  meconium 
where  attempts  at  intra- uterine  inspiration  have  been  made. 

The  cerebral  sinuses  are  engorged  with  blood,  and  there  is 
some  edema  of  the  membranes  covering  the  brain. 

In  extra-uterine  asphyxia  the  markings  or  alterations  in  the 
shape  of  the  head  will  often  be  seen  when  pressure  has  been  the 
cause. 

In  the  lungs,  on  postmortem  examination,  areas  of  unexpanded 
vesicles  will  frequently  be  found.  The  veins  and  the  right  division 
of  the  heart  are  distended.  In  the  head  congestion  of  the  cere- 
bral sinuses  and  meninges,  or  hemorrhages  into  the  latter,  may 
be  present. 

Symptoms. — The  symptoms  of  intra-uterine  asphyxia  can 
only  be  determined  by  close  observation  of  the  child  while  in 
the  womb.  On  auscultation  a  very  slow  or  very  rapid  pulse  will 
indicate  either  pneumogastric  irritation  or  paralysis. 

As  the  asphyxia  continues  muscular  spasms  and  unusual  move- 
ments of  the  child  may  be  observed.  A  practical  point  to  be 
gained  from  the  symptoms  is  that  the  movements  and  heart-beat 
of  the  child  should  be  carefully  examined  before  deciding  on 
operative  or  other  methods  of  delivery.  When  the  umbilical 
cord  is  tightly  wound  about  the  child's  neck  or  arm,  a  bruit, 


ASPHYXIA    XEOXATORUM.  47 

synchronous  or  slightly  slower  than  the  fetal  pulse,  can  be  heard 
by  auscultation  over  the  mother's  abdomen. 

Antepartum  asphyxia  may  be  suspected  whenever  a  fetal 
heart-beat  previously  regular  becomes  either  very  rapid  or  very 
slow  and  faint,  or  when,  by  vaginal  examination,  the  pulsations 
of  the  umbilical  cord  weaken  or  cease,  or  meconium  is  passed  by 
the  fetus. 

The  symptoms  of  postpartum  asphyxia  vary  considerably  in 
the  sthenic  and  asthenic  forms.  In  the  sthcnic,  or  livid,  variety 
the  cutaneous  surfaces  are  cyanotic,  the  face  is  dusky  or  blue  in 
color,  the  muscles  retain  their  tone,  and  may  be  somewhat  rigid. 
Cutaneous  irritability  is  present,  and  the  eyeballs  are  prominent, 
with  the  conjunctive  injected. 

The  pulsations  of  the  cord  are  strong  and  full,  the  respirations 
intermittent,  and  reflexes  may  be  excited  by  irritation.  In  the 
asthenic  or  pallid  form  the  body  is  pale  and  limp  and  the  extrem- 
ities are  quite  cool.  The  face  is  white  and  death-like,  and  the 
lips  are  blue.  The  muscular  system  is  relaxed,  and  there  is  little 
cutaneous  irritability.  The  heart-sounds  are  slow,  irregular,  and 
often  so  feeble  that  it  is  difficult  to  tell  whether  pulsation  exists 
or  not.  Relaxation  of  the  anal  sphincter  is  common.  The  cord 
is  often  thin  and  pale,  while  its  vessels  are  nearly  empty.  This 
sort  of  asphyxia  is  often  seen  in  infants  of  deficient  general  de- 
velopment. Not  infrequently  such  a  child  may  make  a  few 
irregular  spasmodic  attempts  at  respiration,  the  latter  soon 
ceasing,  the  heart-beats  becoming  slower  and  feebler,  and 
death  results,  or  the  child  may  survive  a  few  hours  and  then 
expire. 

Prognosis. —  The  prognosis  will  depend  greatly  on  the 
promptness  and  efficiency  of  the  treatment.  Asphyxia  in  the 
new-born  rarely  tends  to  spontaneous  recovery.  As  a  rule,  the 
prognosis  in  the  asthenic  form  is  the  more  unfavorable.  If  aus- 
cultation for  five  minutes  fails  to  reveal  any  heart-beats,  the  case 
is  hopeless  ;  otherwise  efforts  at  resuscitation  should  be  continued 
as  long  as  any  action  of  the  heart  can  be  detected.  An  unfav- 
orable symptom  is  the  continued  weakening  of  the  heart  and 
lowering  of  temperature  notwithstanding  all  treatment.  It  must 
be  borne  in  mind  in  the  prognosis  that  the  dangers  of  asphyxia 
are  not  over  with  the  immediate  preservation  of  life,  as  the  child 
may  later  perish  from  atelectasis,  inspiration  pneumonia,  or  from 
the  effects  of  cerebral  compression  or  hemorrhage. 

Treatment. — The  treatment  of  asphyxia  in  the  new-born  is 
divided  into  prophylactic  and  curative. 

The  prophylactic  treatment  consists  of  avoiding,  so  far  as  pos- 


48 


DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 


sible,  impediment  to  the  fetal  circulation  by  the  correction  of 
faulty  presentations,  the  judicious  use  of  forceps,  or,  when  the 
child  can  not  be  saved  by  these  means,  the  decision  upon  suit- 
able operative  procedures  for  its  delivery. 

Curative  Treatment. — When  a  moderate  degree  of  asphyxia  is 
present,  the  feet  of  the  child  should   be  grasped  firmly  and  in 


FIG.  2. — SCHULTZE'S  METHOD  (INSPIRATION). 


such  a  manner  as  to  prevent  its  slipping  from  the  physician's 
hands,  and  the  head  be  allowed  to  hang  downward,  in  order 
that  the  blood  may  gravitate  toward  the  brain.  While  the 
infant  is  in  this  position  the  nurse  should  quickly  mop  the 
mouth  and  upper  part  of  the  throat  with  a  piece  of  soft  rag  wet 
with  hot  water,  in  order  to  remove  any  mucus  which  may 
obstruct  the  air-passages. 


ASPHYXIA    NEONATORUM.  49 

The  next  procedure  consists  of  placing  the  child  in  a  hot  bath 
at  a  temperature  of  about  100°  F.  (37.8°  C),  and  pouring  or 
dashing  a  thin  stream  of  cold  water  upon  the  chest  or  back  ; 
slapping  the  buttocks  with  a  towel  wet  with  cold  water  is  often 
useful. 

If   these    methods   are    not   successful,    the   mucus   or    fluids 


FIG.  3. — SCHULTZE'S  METHOD  (EXPIRATION). 

obstructing  the  air-passages  should  be  removed  by  suction 
through  a  soft  india-rubber  catheter  passed  into  the  trachea. 
Irritation  applied  to  the  skin,  or  blowing  air  over  the  child  by 
means  of  a  bellows  or  fan,  occasionally  does  good. 

If  the  child  still  fails  to  respond,  a  soft  catheter  should  be 
passed  into  the  larynx  and  the  lungs  inflated,  or  the  same  result 
may  be  brought  about  by  Richardson's  bellows. 
4 


5<D  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

When  a  greater  degree  of  asphyxia  exists,  any  one  or  all 
of  the  following  manipulations  should  be  used  successively  : 
ScJiultzc's  method  (see  Figs.  2  and  3). — The  physician,  standing 
with  the  body  slightly  bent  forward  and  the  legs  moderately 
separated,  the  arms  extending  toward  the  ground,  seizes  the  in- 
fant by  the  axillae  in  such  a  manner  that  his  index-fingers  are 
passed  from  behind  forward,  the  back  of  the  infant  being  toward 
the  operator.  The  thumbs  rest  gently  over  the  clavicles,  against 
the  posterior  surfaces  of  which  the  remaining  fingers  are  applied 
in  a  direction  from  above  downward. 

The  infant's  head  is  supported  against  the  operator's  wrists, 
who,  while  thus  holding  it,  quickly  raises  the  infant  forward  and 
upward  until  the  operator's  arms  are  somewhat  above  the  hori- 
zontal line  ;  the  infant's  body  is  now  in  a  state  of  extreme  ex- 
tension, and  inspiration  is  produced  thereby. 

At  the  moment  when  the  operator's  arms  are  somewhat  above 
the  horizontal  the  motion  is  suddenly  stopped,  thus  allowing  the 
infant's  body  to  flex  upon  itself  in  front  of  the  operator's  face. 
This  movement  flexes  the  infant's  spine  and  compresses  the 
thorax  and  abdomen,  thus  producing  expiration. 

The  infant  is  now  returned  to  the  first  position,  and  the  man- 
ipulations are  repeated  at  about  the  rate  of  from  eighteen  to 
twenty  times  a  minute. 

Sylvester's  Method. — Place  the  infant  on  its  back,  with  a  small 
rolled  towel  between  the  shoulders,  so  as  to  extend  the  abdomen 
and  thorax.  Now  grasp  the  arms  above  the  elbows  and  bring 
them  quickly  upward  by  the  side  of  the  head,  at  the  same  time 
everting  them.  Next  bring  them  down  again  against  the  sides 
of  the  chest,  and  make  gentle  but  firm  pressure.  The  move- 
ments should  be  repeated  at  intervals  corresponding  with  those 
of  normal  respiration. 

Laborde's  Method. — This  consists  of  laying  the  child  on  a  flat 
surface,  with  a  small  rolled  towel  between  its  shoulders.  It  is 
generally  recommended  that  the  head  and  neck  be  in  the  state 
of  considerable  extension.  The  tongue  is  seized  with  a  pair  of 
hemostatic  or  other  small  forceps,  and  drawn  out  and  in  with  a 
rhythmic  motion,  the  frequency  of  which  should  correspond 
with  those  of  normal  respirations.  It  is  recommended  that  this 
traction  of  the  tongue  be  supplemented  by  motions  of  the  arms, 
as  in  Sylvester's  method. 

A  modification  of  the  so-called  Byrd-Dew  method  will  often 
be  found  very  successful  and  is  to  be  recommended.  This  consists 
in  grasping  the  child  by  the  buttocks  with  the  left  hand,  holding 
it  in  such  a  position  that  the  head  will  be  lower  than  the  body, 


ASPHYXIA    NEONATORUM.  51 

the  thumb  and  forefinger  of  the  right  hand  being  placed  around 
the  neck.  The  left  hand  then  raises  the  body,  bending  the  latter 
over,  and  during  this  movement  the  thumb  and  first  finger  of 
the  right  hand  are  making  pressure  against  the  thorax  ;  this  con- 
stitutes expiration.  The  second  movement  consists  of  extending 


FIG.  4. — SYLVESTER'S  METHOD  (EXPIRATION). 


FIG.  5. — SYLVESTER'S  METHOD  (INSPIRATION). 


the  body  or  straightening  it  out,  the  thumb  and  first  finger  of  the 
right  hand  at  the  same  time  releasing  their  pressure  upon  the 
chest-wall  ;  this  constitutes  the  act  of  inspiration.  The  arms  may 
be  allowed  to  hang  down,  or,  better,  may  be  partially  supported 
by  the  other  fingers  of  the  right  hand  and  the  body  of  the  opera- 


52  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

tor.  It  is  well  to  have  the  lap  covered  with  a  blanket  or  a  rub- 
ber sheet  in  order  to  protect  the  clothes.  The  movement  should 
be  repeated  from  eighteen  to  twenty  times  a  minute.  The  fara- 
dic  current  is  also  very  useful  in  many  of  these  cases. 

MoutJi-to-inoutli  Insufflation. — The  air-passages  of  the  child  hav- 


FIG.  6. — ARTIFICIAL  RESPIRATION  (INSPIRATION). 


FIG.  7. — ARTIFICIAL  RESPIRATION  (EXPIRATION). 


ing  been  cleansed  of  mucus,  the  physician  places  his  mouth  to  that 
of  the  child  and  expires  with  some  force  into  its  air-passages.  At 
the  end  of  each  expiration  (the  child's  inspiration)  pressure  is  made 
on  the  child's  thorax  and  abdomen,  so  as  to  cause  the  infant  to 
force  the  air  from  its  lungs.  It  is  unnecessary  to  close  the  child's 


ASPHYXIA    NEOXATORUM.  5  3 

nostrils  during  its  inspiration.  Direct  insufflation  can  sometimes 
be  made  by  passing  a  soft  catheter  into  the  larynx  and  gently  in- 
flating the  lungs,  either  by  expiring  into  them  or  by  the  use  of 
the  apparatus  of  Depaue  or  Ribmont. 

In  cases  of  late  asphyxia  following  nonexpansion  of  the  lungs, 
our  efforts  should  be  directed  toward  exciting  more  active  respira- 
tion. 

The  stupor  which  sometimes  appears  is  to  be  treated  by  appli- 
cation of  hot  and  cold  water  to  the  head  and  body,  or  some  stim- 
ulating liniment  may  be  used. 

Unfortunately,  the  dangers  of  asphyxia  do  not  end  with  the 
resuscitation  of  the  child,  and  this  is  especially  the  case  in  the 
pallid  or  asthenic  form.  In  many  of  these  patients  the  first 
respiratory  efforts  are  so  feeble  that  only  small  areas  of  the  lungs 
are  inflated.  What  expansion  does  take  place  occurs  near  the 
surface  of  the  lung.  Frequently  not  enough  expansion  occurs 
to  allow  of  the  aeration  of  sufficient  blood  to  support  life. 


FIG.  8.— RIBMONT'S  TUBE. 


Atelectasis  frequently  occurs.  In  treating  the  pallid  form  of 
asphyxia  a  good  plan  is  to  immerse  the  infant  in  a  hot  mustard 
bath  at  a  temperature  of  1 10°  F.  (43.3°  C.).  A  small  stream  or 
spray  of  cold  water  may  be  poured  on  the  chest  from  time  to 
time.  In  addition  to  the  methods  of  artificial  respiration  described, 
hypodermic  injections  of  minute  quantities  of  stimulants,  such  as 
aromatic  spirits  of  ammonia,  strychnin,  atropin,  and  brandy  may 
be  used  with  good  effect.  These  patients  require  careful  watch- 
ing for  several  days.  Artificial  respiration  and  general  stimula- 
tion should  be  repeated  if  necessary. 

In  the  after-treatment  the  indications  are  two  :  warmth  and  fre- 
quent, regular  feeding  of  small  quantities  of  suitable  food.  Heat 
at  a  regulated  temperature  can  be  obtained  by  wrapping  the  child 
in  raw  cotton  or  wool  and  placing  it  in  a  padded  basket  near  the 
fire,  with  one  or  two  bottles  of  hot  water  near  it  and  a  bath  ther- 
mometer inserted  near  the  body.  A  better  method  is  to  place 
the  child  in  the  couveuse,  or  incubator,  the  one  designed  by 
Auvard,  or  one  of  its  modifications,  being  about  the  most  conven- 


54 


DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 


ient.  The  apparatus  consists  of  a  glass-covered  box  in  which  a 
small  basket  or  pillow  is  placed  upon  a  false  bottom  on  which  the 
infant  lies.  Warm  air  is  generated  beneath  the  false  bottom  by 
means  of  cans  filled  with  hot  water.  The  air,  admitted  at  a  small 
door  beneath  the  false  bottom  at  one  end  of  the  box,  is  heated 
by  its  passage  over  the  cans  filled  with  hot  water,  then  passes  up 
through  the  chamber  in  which  the  child  lies,  and  escapes  out 
through  a  tube  in  the  top.  In  this  tube  a  small  revolving  fan  is 
sometimes  placed  to  secure  better  ventilation. 


FIG.  9. — DIAGRAM  OF  TARNIER  COUVEUSE. 


THE    MANAGEMENT   OF   INFANTS    PREMATURELY 

BORN. 

The  fundamental  principles  for  the  care  of  prematurely  born 
infants  are  to  be  learned  from  a  study  of  intra-uterine  life.  The 
prematurely  born  infant  must  be  carefully  protected  from  cold 
and  changes  of  temperature :  in  other  words,  it  should  live  in  an 
atmosphere  the  degree  of  heat  of  which  is  kept  as  near  that  of  the 
mother's  body  as  possible.  It  should  receive  a  plentiful  supply 
of  pure  warm  air,  and  as  the  eyes  are  as  yet  but  incompletely 
developed,  they  should  be  protected  from  light  by  keeping  the 
child  in  the  dark.  Nourishment  must  be  given  by  the  mouth  in 
the  most  digestible  form  possible,  in  small  quantities,  and  at 
regular  frequent  intervals. 

Temperature. — A  prematurely  born  infant  often  loses  from  five 
to  nine  degrees  of  bodily  heat  in  an  hour  after  birth  (Eross). 
This  rapid  loss  is  partly  due,  in  very  premature  infants,  to  the 


THE    MANAGEMENT    OF    INFANTS    PREMATURELY    BORN.  55 

almost  entire  absence  of  subcutaneous  fat  and  to  the  greater  pro- 
portionate surface  area  of  the  body  (Blacker).  Another  factor  to 
be  considered  is  that  on  account  of  the  general  feebleness  of  these 
infants  and  their  weak  digestive  powers  they  can  not  produce 
much  heat  in  themselves. 

Light. — On  account  of  the  imperfect  development  of  the  eyes, 
these  should  be  carefully  protected  from  light  until  the  infant  has 
arrived  at  full  term.  This  can  be  done  by  covering  the  glass  top 
of  the  incubator  with  a  piece  of  dark-green  or  black  cloth. 

Nourishment. — Every  premature  infant  should  be  carefully 
weighed  at  frequent  regular  intervals,  at  first  every  day,  unless  it 
be  too  feeble.  It  is  only  by  this  means  that  the  increase  or  de- 
crease in  the  child's  development  can  be  studied.  The  average 
daily  increase  in  weight  varies  with  the  total  weight  of  the  child, 
and  is,  of  course,  less  than  in  full-term  children.  This  increase 
may  amount  to  from  ^  to  ^  of  an  ounce  a  day,  and  is  by  no 
means  constant,  even  if  the  child  be  thriving.  It  must  be  remem- 
bered that  these  children  often  remain  stationary,  as  far  as  weight 
is  concerned,  for  days  at  a  time ;  therefore  as  long  as  there  is  no 
actual  loss,  no  anxiety  need  be  felt.  Should  a  steady  decrease 
in  weight  occur,  the  child's  life  is  in  danger  and  a  careful  inves- 
tigation must  be  made  for  the  cause.  A  very  slight  loss  of 
weight  is  sufficient  to  cause  death. 

The  first  indication  in  the  treatment  of  these  infants  is  to  keep 
them  in  a  warm  atmosphere  of  as  nearly  even  temperature  as 
possible,  and  this  can  only  be  properly  done  by  the  use  of  the 
couveuse,  or  incubator,  one  form  of  which  has  been  described. 

The  temperature  of  the  incubator  should  at  first  be  kept  at  from 
90°  to  95°  F.,  according  to  the  general  condition  of  the  child:  thus, 
if  its  extremities  are  cold  or  its  temperature  subnormal,  the  tem- 
perature of  the  incubator  must  be  raised ;  on  the  other  hand,  if 
perspiration  appears  on  the  child's  body,  this  is  at  once  an  indi- 
cation for  reducing  the  temperature  of  the  couveuse.  If  the  child 
continues  to  thrive,  the  temperature  of  the  couveuse  must  be 
gradually  lowered,  so  that  when  the  child  is  removed,  it  may  not 
be  injured  by  the  temperature  of  the  ordinary  room,  which  is 
about  70°  F. 

It  is  highly  essential  that  the  air  which  the  child  receives 
should  be  as  pure  as  possible  ;  therefore  the  incubator  should  be 
placed  in  a  well-ventilated  room.  An  upper  room  considerably 
above  the  ground-level  will  generally  answer  best.  The  air 
entering  the  incubator  should  be  slightly  moist  and  well  filtered. 
In  hospitals  this  can  be  done  by  having  the  incubator  supplied  with 


DISEASES    OCCURRING    AT    OK    NEAR    BIRTH. 


outside  air  passed  over  water  or  through  moist  cotton.  In 
private  houses  a  wet  sponge  placed  in  a  small  rack  in  the  incu- 
bator, so  that  the  incoming  air  can  pass  through  it,  will  answer 
the  purpose  quite  well.  It  is  generally  considered  best  not  to 
bathe  a  premature  infant,  at  least  during  the  period  of  its  incu- 
bator life  ;  instead  it  should  be  enveloped 
in  cotton-wool,  which  can  be  changed  twice 
a  day  or  when  necessary.  Oils  and  oint- 
ments are  contraindicated. 

The  feeding  is  a  most  important  factor 
in  the  treatment  of  these  infants  ;  many  of 
them  do  well  on  their  mother's  milk,  and 
in  all  cases  an  attempt  should  be  made 
to  feed  the  child  with  this.  The  milk 
should  be  drawn  from  the  breast  by  a 
clean  breast-pump.  If  the  child  is  old 
enough  to  suck,  it  may  be  successfully  fed 
by  the  instrument  devised  by  Breck.  This 
consists  of  a  graduated  glass  cylinder  hold- 
ing about  nine  drams.  It  is  shaped  at  one 
end  so  as  to  hold  a  small  rubber  nipple. 
The  large  end  is  covered  by  a  small  "  cot " 
or  air  reservoir.  To  fill  the  tube,  the 
rubber  nipple  and  cot  are  removed,  and  the 
opening  at  the  nipple  end  closed  with  a 
rubber  plug.  The  food  is  then  poured  in 
the  large  end.  In  feeding  the  child  the 
plug  is  withdrawn  and  the  nipple  and  cot 
replaced  ;  the  nipple  is  introduced  into  the 
mouth,  and  by  gently  pressing  the  rubber 
cot  the  food  is  slowly  forced  down  the 
infant's  throat  without  any  danger  of  chok- 
ing it  or  the  expenditure  of  its  strength. 
If  such  an  instrument  can  not  be  had,  or  if 
the  infant  be  too  feeble  to  suck,  it  may.  be 
fed  from  a  curved  medicine  dropper  or 
even  by  a  spoon.  If  the  administration 

of  food  by  the  dropper  causes  vomiting,  the  child  must  be 
fed  by  gavage.  A  small  soft  catheter  is  introduced  into  the 
stomach,  and  the  food  poured  in  by  means  of  a  funnel.  This 
method  is,  however,  much  more  uncomfortable  for  the  child 
than  feeding  by  the  dropper,  and  should  only  be  used  when 
all  other  means  have  failed. 

In   some  cases  mother's   milk,   even  when  diluted,   will   not 


—  4. 


FIG.  10. — BRECK'S  INFANT 
FEEDER. 


THE  MANAGEMENT  OF  INFANTS  PREMATURELY  BORN. 


57 


agree  with  the  infant,  this  being  explained  by  the  fact  that  up  to 
the  end  of  pregnancy,  and,  indeed,  for  some  days  afterward,  the 
secretion  of  the  mammary  glands  is  colostrum  rather  than  true 
milk.  This  colostral  type  of  milk  is  nearly  always  present  at 
the  time  of  or  follows  premature  birth  of  the  child,  and  analysis 
of  it  shows  that  it  contains  an  excess  of  proteids  with  a  relative 
deficiency  of  sugar  and  fat.  It  is  on  this  that  its  laxative  prop- 
erties and  tendency  to  cause  indigestion  are  supposed  to  depend. 


FIG.  ii. — MODIFICATION  OF  TARNIKR  COUVEUSE,  IN  USE  IN  THE  JEFFERSON  MATERNITY, 

PHILADELPHIA. 

As  a  rule,  the  more  premature  the  birth,  the  longer  the  colostral 
character  of  the  milk  continues. 

The  stomach  of  the  premature  infant  is  a  very  small  and  deli- 
cate organ,  and  its  digestive  fluids  are  weak  ;  therefore  it  is  highly 
important  that  the  food  which  is  put  into  it  shall  be  such  that  it  can 
be  easily  and  quickly  digested  and  assimilated.  If  this  is  not  the 
case,  the  child  will  lose  weight  and  its  chances  of  surviving  are 
much  diminished.  It  is  important,  therefore,  that  if  the  mother's 
milk,  plain  or  diluted,  does  not  agree  from  the  first,  it  must  be 
stopped  and  some  easily  digested  artificial  food  be  substituted  for 
it.  Whatever  food  is  used  should  be  given  in  very  small  quan- 


58  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

titles,  often  not  more  than  a  dram  at  a  time,  and  this  must  be  re- 
peated frequently.  The  simplest  food  to  use  in  feeding  prema- 
ture infants  is  a  mixture  of  equal  parts  of  peptonized  milk  and 
barley-water,  and  of  this  a  teaspoonful  may  be  given  every  two 
hours  ;  but  much  better,  in  our  experience,  is  cow's  milk,  so 
modified  that  the  amount  of  proteid  shall  be  exceedingly  small. 
Some  of  the  formulas  of  Rotch  will  be  found  very  useful  for  this 
purpose.  As  every  infant,  no  matter  how  young,  is  a  "  law 
unto  itself,"  every  patient  must  be  studied  with  the  utmost  care. 
A  given  milk  formula  must  be  studied  in  the  light  of  the  digesti- 
bility of  each  and  all  of  its  elements,  and  when  these  are  taken  up 
by  the  child's  digestive  organs  and  assimilated,  the  child  thrives  ; 
otherwise  it  will  rapidly  lose  ground.  If  a  formula  is  not  agreeing, 
as  a  rule  the  element,  be  it  fat,  sugar,  or  proteid,  which  is  in  ex- 
cess and  which  is  causing  the  trouble  will  show  itself  by  the 
symptoms  it  produces,  and  so  the  reducing  of  it  is  an  easy  mat- 
ter. As  a  first  milk  formula  the  authors,  in  common  with  many 
others,  have  had  good  success  with  the  following  prescription  of 
Rotch's  : 

Fat, i.oo 

Sugar 3.00 

Proteid, 0.50 

Lime-water,     . 5.00 

This  can  be  made  as  follows : 

Cream,      2}4  fluidrams 

Milk, y2  fluidram 

Lime-water, 1%  fluidrams 

Milk-sugar,  ^  measure  (or  ^  ounce),  or  cane-sugar, 

half  the  quantity,  Pasteurized  at  a  temperature  of 

167°  F. 

The  child  should  receive  one  dram  at  a  feeding  every  hour  or 
two.  If  this  agrees,  the  elements  can  be  very  gradually  increased, 
until,  by  the  thirty-sixth  week,  it  is  possible  the  child  may  take 
the  following  : 

Fat, 2.00 

Sugar, 5-5° 

Proteid, i.oo 

Lime-water, 5'°° 

This  is  made  as  follows  (the  quantity  here  given  is  for  an 
average  twenty-four  hours'  feeding)  : 

Cream 4      ounces 

Milk, i)4      " 

Lime-water, I      ounce 

Water,      13^  ounces 

20      ounces 
Milk-sugar,      2\    measures. 


HEMORRHAGES    IN    THE    NEW-BORN.  59 

If  the  first  formula  does  not  agree,  the  element  in  excess  must 
be  sought  for  and  reduced.  If,  on  the  other  hand,  the  food  agrees 
and  the  infant  does  not  gain  in  weight  as  fast  as  it  ought  to, 
a  richer  food  is  demanded.  As  a  rule,  some  modification  of 
cow's  milk  which  will  answer  all  purposes  can  be  made  by  the 
mother  or  nurse  at  home.  A  little  patience  on  the  part  of  the 
doctor  and  nurse  and  some  knowledge  of  the  physiology  of  the 
infant's  digestive  apparatus  will  enable  them  to  make  up  a  food 
which  will  meet  all  requirements.  The  use  of  condensed  milk, 
boiled  milk,  or  patent  foods,  as  advised  by  some  authors,  we  must 
condemn. 

If  the  infant  be  very  feeble,  a  few  drops  of  brandy  may  be 
given  every  two  or  three  hours  as  long  as  necessary,  and  if 
cyanosis  should  at  any  time  appear,  oxygen  may  be  administered 
for  five  or  ten  minutes  two  or  three  times  a  day. 


DISEASES  IN  THE  NEW-BORN  CHARACTERIZED 
BY    HEMORRHAGE. 

HEMORRHAGES  IN  THE  NEW-BORN. 

Causes. — Hemorrhage  in  early  life  may,  as  in  the  adult,  de- 
pend upon  an  alteration  in  the  condition  of  the  blood  itself  or 
upon  direct  injury  to  the  blood-vessels. 

As  instances  of  the  first  we  have  the  extensive  disintegration 
of  the  blood,  found  in  syphilitic  infants  and  after  the  acute  fevers, 
such  as  typhus,  scarlet  fever,  etc. 

Intra-uterine  infection  of  the  fetus  by  micrococci  may  be  a 
cause  of  hemorrhage. 

Hemorrhages  from  the  navel  following  infection  are  also  in- 
stances of  this  class.  Tavel  and  Quervian  have  reported  a  case 
in  which  death  on  the  thirteenth  day  after  birth  followed  an  in- 
fection of  the  umbilicus  occurring  immediately  after  the  child 
was  born.  Postmortem  examination  in  this  case  showed  hem- 
orrhages into  the  connective  tissue,  beneath  the  epidermis,  the 
mucous  and  serous  membranes,  and  in  the  kidneys.  Direct 
evidences  proved  these  hemorrhages  to  be  caused  by  streptococ- 
cus-infection. 

In  a  second  case  death  occurred  from  pneumonia  which  was 
the  result  of  staphylococcus-infection,  as  was  proved  by  subse- 
quent examination.  The  hemorrhages  had  occurred  into  the 
parenchyma  of  all  the  organs  examined. 


6O  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

Symptoms. — The  symptoms  in  the  majority  of  cases  of 
hemorrhage  are  very  obscure.  Bleeding  occurs  from  the  um- 
bilicus and  mucous  surfaces  internally,  externally,  or  both. 
Subcutaneous  hemorrhages  (petechiae)  are  common.  The  infant 
usually  ceases  to  nurse,  and  is  somnolent  and  pale.  Later,  con- 
vulsions and  irregular  respirations  develop,  and  the  child  dies. 
A  proper  study  of  these  cases  can  be  completed  only  by  making 
a  postmortem  examination  of  all  infants  dying  of  obscure  symp- 
toms. 

APOPLEXY  IN  THE  NEW-BORN. 

Synonyms. — CEREBRAL  OR  MENINGEAL   HEMORRHAGE  ;  ASPHYXIA 
RUBRA  SEU  APOPLECTICA  ;    HYPER^EMIA   CEREBRI  TRAUMATICA. 

Definition. — Cerebral  hemorrhage  occurring  in  early  life. 
The  term  is,  however,  often  used  to  cover  all  degrees  of  in- 
creased cerebral  blood  pressure. 

Causes. — The  most  frequent  cause  is  pressure  during  birth  or 
continued  compression  of  the  head  by  forceps.  It  may,  however, 
follow  pressure  on  the  umbilical  cord  during  a  breech  presenta- 
tion or  otherwise  prolonged  labors. 

Apoplexy  in  the  new-born  is  most  generally  the  result  of  a 
venous  congestion  of  the  vessels  of  the  pia  mater  or  choroid 
plexus. 

Pathology. — Following  distention  of  the  cerebral  sinuses  by 
asphyxia  or  other  causes,  or  a  rupture  in  the  capillary  vessels  of 
the  pia  mater,  the  blood  is  effused  into  the  subarachnoid  space. 
As  in  the  very  young  the  connection  between  the  inner  covering 
of  the  brain  and  the  cerebral  tissue  is  not  intimate,  the  area  of 
hemorrhage  may  extend  over  a  large  surface  or  burst  into  the 
subdural  space,  compressing  the  brain  substance — indeed,  an 
actual  laceration  of  the  brain  tissue  may  occur,  leading  to  a  sec- 
ondary softening.  Engorgement  of  the  superficial  cerebral  veins 
may  take  place  :  as,  according  to  Gowers,  the  ascending  arteries 
pass  into  the  ascending  veins,  and  these  empty  themselves  into 
the  superior  longitudinal  sinus  in  a  forward  direction  and  conse- 
quently against  the  blood  current. 

Spencer  and  McNutt  have  concluded  that  while  in  most  cases 
apoplexy  in  the  new-born  is  seen  in  children  delivered  after  diffi- 
cult labors  or  where  the  forceps  have  been  used,  it  sometimes 
occurs  after  short  and  easy  labors,  and  one  of  the  writers  has 
recorded  a  case  in  which  an  infant  born  in  breech  presentation 
and  by  an  easy  labor  presented  the  following  symptoms  :  shortly 
after  birth  the  breathing  became  irregular,  and,  later,  difficulty  in 


APOPLEXY    IN    THE    NEW-BORN.  6 1 

swallowing,  convulsions,  left-sided  hemiplegia,  and  rapid  emacia- 
tion made  their  appearance. 

The  length  of  the  child's  life  was  twenty-two  days.  At  the 
autopsy  it  was  found  that  a  clot  covered  the  right  hemisphere, 
this  clot  being  gelatinous  and  firm  and  of  a  dark  color.  Not 
only  the  convolutions  beneath  it  were  in  part  destroyed,  espe- 
cially in  the  frontal  and  parietal  regions,  but  also  the  brain  tissue 
covering  the  ventricle,  while  the  sites  of  the  corpus  striatum  and 
optic  thalamus  were  occupied  by  a  reddish-brown  clot  mixed 
with  softened  brain  substance. 

The  blood  may  be  extravasated  in  points  here  and  there  over 
the  entire  brain,  or  may  only  occupy  a  part  of  the  organ.  In 
other  cases  extravasation  may  take  place  in  one  or  perhaps  two 
of  the  cavities  in  the  same  manner  as  in  ordinary  apoplexy.  In 
the  first  form  there  is  little  laceration  or  injury  to  the  brain  sub- 
stance. The  cerebral  tissue  surrounding  the  hemorrhagic  points 
sometimes  preserves  the  normal  appearance,  being  white  and  firm. 
Occasionally,  however,  it  may  present  a  reddish  or  yellowish 
appearance,  being  softened  to  a  depth  of  a  line  or  two.  When 
the  hemorrhage  occurs  into  a  cavity,  in  the  same  manner  as  in 
apoplexy  of  adults,  the  nerve-fibers  are  generally  torn  and  sepa- 
rated. In  these  cases  there  is  sure  to  be  more  or  less  compres- 
sion of  the  surrounding  brain  substance.  Unless  the  disease  be 
of  long  standing,  the  cavity  contains  a  dark,  soft  clot,  bathed 
with  serum.  The  brain  substance  in  the  immediate  vicinity  is 
softened. 

Partial  or  complete  asphyxia  will  cause  intense  congestion  and 
engorgement  of  the  cerebral  vessels,  being  accompanied  or  fol- 
lowed by  hemorrhage  on  or  into  the  brain  tissue  in  many 
instances,  and,  as  a  result,  there  will  frequently  be  found  a 
chronic  meningo-encephalitis,  a  sclerosis,  or  an  atrophy  of  a 
part  of  the  brain,  which  in  a  certain  percentage  of  cases  may  be 
followed  by  chronic  paralysis  or  deficient  mental  development. 

Symptoms. — The  infant,  which  at  the  moment  of  birth  may 
evince  no  particular  symptoms,  in  a  few  hours  becomes  cyanosed. 
More  or  less  projection  of  the  eyeballs  may  be  present  and  the 
tongue  possibly  be  protruded.  If  the  hemorrhage  is  at  the  base 
of  the  brain  or  is  severe,  the  cardiac  action  and  respirations 
become  weak  and  irregular,  and  the  child  dies  in  collapse.  If 
the  effusion  is  small  or  is  in  the  cortex,  or  if  simple  hyperemia 
without  rupture  is  present,  the  child  may  recover.  It  should 
not,  however,  be  forgotten  that  permanent  paralysis,  convulsions, 
or  even  idiocy  may  follow  such  a  condition. 

Davis  cites  a  case  in  which  an  infant  delivered  with  axis-trac- 


62  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

tion  forceps  without  difficulty  displayed  symptoms  of  progressive 
feebleness  of  respiration.  Failure  to  nurse  and  apparent  exhaus- 
tion caused  death  in  thirty-six  hours  after  birth.  A  postmortem 
examination  showed  the  tissues  of  the  scalp  to  be  intensely  con- 
gested, but  no  gross  lesion,  either  rupture  or  fracture,  was  pres- 
ent. The  cortex  of  the  cerebrum  was  filled  with  punctate  hem- 
orrhages, and  over  the  point  of  greatest  convexity  the  brain 
substance  was  materially  softened.  Virchow  and  others  have 
shown  that  the  blood-vessels  of  the  infant's  brain  are  thin  and 
small,  and  most  readily  injured  by  abnormal  pressure. 

Treatment. — The  indications  for  treatment  are  mostly  pro- 
phylactic, and  care  should  be  taken  to  prevent  excessive  birth 
pressure  by  prompt  deliverance  of  the  child  by  forceps  or  suit- 
able operative  procedure.  There  is  much  more  danger  in  the 
continued  pressure  on  the  child's  head  by  the  maternal  parts 
during  a  long  labor  than  by  a  skilful  forceps  delivery.  On  the 
other  hand,  undue  pressure  on  the  fetal  head  by  the  forceps  or 
the  forcible  rotation  of  the  same  should  be  avoided.  After  cere- 
bral hemorrhage  has  occurred  but  little  can  be  done  for  the 
patient  except  to  keep  the  infant  as  quiet  as  possible  and  relieve 
symptoms  as  they  arise. 

HEMORRHAGES  FROM  MUCOUS  SURFACES. 

Causes. — Hemorrhages  from  various  mucous  membranes  of 
new-born  infants  result  most  frequently  from  malnutrition  and  its 
consequent  anemia  or  from  hemophilia.  They  may  also  be  caused 
by  congestion  of  the  pelvic  organs,  due  to  the  sudden  cessation 
of  the  flow  of  blood  through  the  umbilical  arteries. 

The  most  common  site  of  such  hemorrhages  is  from  the 
mucous  membrane  of  the  vagina  in  female  infants,  although  it 
may  occasionally  occur  from  the  rectum  or  mouth,  and,  rarely, 
from  the  nose. 

Treatment. — When  the  hemorrhage  is  the  result  of  simple 
congestion  in  a  robust,  hearty  child,  no  treatment  is  required. 
When  the  infant  is  anemic,  it  is  well  to  employ  minute  doses  of 
arsenic,  careful  regulation  of  the  nursing,  and  inunctions  of  olive 
or  cod-liver  oil,  combined  with  soap  liniment  in  the  proportion  of 
about  three  parts  of  the  former  to  one  part  of  the  latter. 

When  the  bleeding  surface  can  be  reached,  applications  of  a 
solution  of  boric  acid  or  a  hot  mixture  of  creolin  and  water,  one 
dram  to  the  quart,  are  useful. 

When  the  hemorrhage  is  the  result  of  simple  congestion  or 
anemia,  the  prognosis  is  good. 


CAPUT    SUCCEDANEUM.  63 


CAPUT  SUCCEDANEUM. 
Synonyms.  —  SUPPLEMENTARY    HEAD;     SPURIOUS     CEPHALHEMA- 

TOMA  ;     SUBAPONEUROTIC    CEPHALHEMATOMA  ;    KOPFGESCHWULST. 

Definition. — A  tumor  upon  the  presenting  part  of  the  fetus, 
the  result  of  serosanguineous  infiltration  under  the  skin  and 
subcutaneous  tissue,  due  to  pressure. 

The  tumor  occurs  upon  that  portion  of  the  presenting  part 
of  the  child  which  is  itself  not  subjected  to  pressure. 

The  size  of  a  caput  succedaneum  increases  generally  in  propor- 
tion to  the  length  of  the  labor.  The  color  of  the  tumor  is  bluish 
red,  and  there  is  no  fluctuation  or  pitting  on  pressure. 

Causes. — Continued  pressure  upon  that  portion  of  the  fetal 
skull  which  receives  the  greatest  impact  of  force  during  descent 
and  rotation,  temporarily  checks  the  free  circulation  of  the  blood 
and  lymph  through  the  tissues  of  the  scalp  and  fascia.  On  the 
opposite  side  of  the  vertex  there  remains  a  portion  of  the  scalp 
which  endures  less  pressure  from  the  bony  pelvis,  and  it  is  here  that 
the  blood  and  lymph  of  the  scalp  are  prevented  from  circulating 
through  the  other  side  of  the  fetal  head  by  pressure,  and  tnus 
accumulate,  distending  the  tissues  of  the  side  least  pressed  upon. 
Consequently,  we  find  the  tumor  generally  on  the  side  oppo- 
site to  that  which  is  actually  engaged  in  the  pelvis  in  the  first 
stage  of  labor. 

The  situation  of  the  caput  succedaneum  will  sometimes  give  a 
clue  to  the  position  occupied  by  the  child  in  the  uterus  :  thus, 
in  the  case  of  an  infant  occupying  a  position  with  the  vertex  to 
the  right  anterior  half  of  the  mother's  pelvis  and  the  fetal  back  to 
the  mother's  right,  the  caput  succedaneum  will  be  found  on  the 
left  parietal  portion  of  the  child's  head. 

In  shoulder  presentation  the  tumor  is  found  on  the  presenting 
shoulder. 

Varieties  and  Pathology. — In  cases  in  which  the  labor  is 
very  protracted  and  the  head  subjected  to  long-continued  pres- 
sure, the  caput  succedaneum  may  cover  both  parietal  bones,  and 
this  fact  is  regarded  as  one  of  the  diagnostic  features  between  it 
and  true  cephalhematoma. 

Occasionally  two  tumors,  a  primary  and  a  secondary,  may  be 
found,  and  in  such  cases  the  first  tumor  is  formed  in  the  manner 
previously  described  and  the  second  is  due  to  pressure  after  the 
head  is  rotated  on  the  floor  of  the  pelvis,  the  presenting  part 
being  detained  for  a  considerable  time  in  this  position. 

Treatment. — In   the  majority  of   cases   caput  succedaneum 


64  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

needs  no  treatment.  When  the  tumor  is  very  large,  some  stimu- 
lating evaporating  lotion,  such  as  solutions  of  chlorid  of  ammo- 
nia, camphor  and  alcohol,  or  cold  cream,  may  be  applied  on 
cotton,  which  should  be  held  in  place  by  a  firm  bandage.  As  a 
rule,  the  tumor  need  occasion  no  further  solicitude. 

If  the  tumor  persists,  some  authorities  advise  either  aspiration 
or  incision,  after  which  pressure,  by  means  of  a  pad  of  salicy- 
lated  cotton  and  a  bandage,  should  be  applied.  If,  as  some- 
times happens,  the  tumor  becomes  infected  and  an  abscess  forms, 
it  should  be  opened  under  strict  antiseptic  precautions  and 
treated  in  the  usual  way. 

CEPHALHEMATOMA. 

Synonyms. — THROMBUS  NEONATORUM  ;  ECCHYMOMA  CEPHAL^EM- 

ATOME. 

Definition. — An  elastic,  nonfluctuating  tumor  of  hemispheric 
form,  occurring  usually  on  the  scalp  and  increasing  in  size  after 
birth. 

Causes. — The  causes  of  cephalhematoma  are  obscure,  and 
the  literature  of  the  subject  contains  many  conflicting  statements 
regarding  its  etiology. 

According  to  Ashby  and  Wright,  cephalhematoma  is  in  part 
caused  by  asphyxia,  during  which  there  are  increased  tension  in 
the  cranial  veins  and  an  altered  condition  of  the  blood,  allowing 
extravasations. 

Pressure  would  seem  in  some  cases  to  be  a  cause,  as  might  be 
inferred  from  the  situation  of  the  tumor — namely,  on  the  right 
parietal  bone ;  but  the  literature  of  the  subject  contains  the 
reports  of  a  number  of  cases  in  which  the  tumor  occurred  upon 
parts  which  had  not  been  subjected  to  pressure  during  birth, 
and  one  case  is  recorded  in  which  the  tumor  was  seen  on  the 
head  of  a  child  delivered  after  Cesarean  section. 

Virchow  believes  that  the  pericranium  is  formed  by  a  prolifera- 
tion of  the  inner  layers  of  the  periosteum.  When  separation  of 
the  latter  from  the  bone  by  an  extravasation  of  blood  occurs,  the 
bone-producing  layers  of  the  periosteum  are  still  formed,  but  are 
prevented  by  the  blood-clot  from  uniting  with  that  portion  of  the 
bone  for  which  they  are  intended  ;  they  therefore  join  themselves 
to  the  bone  at  the  border  of  the  extravasated  clot  where  the  bone 
is  yet  attached. 

The  cause  of  cephalhematoma  has  also  been  ascribed  to  trau- 
matism  and  to  alteration  in  the  blood  itself,  this  alteration  being 
due  to  malnutrition. 


CEPHALHEMATOMA.  65 

Regarding  the  frequency  of  cephalhematoma,  it  is  found  more 
often  in  males  than  in  females.  It  occurs  about  once  in  every 
200  births. 

Hennig  noticed  that  it  was  situated  fifty-seven  times  over  the 
right  parietal  bone,  thirty-seven  times  over  the  left,  and  in  twenty- 
one  cases  it  was  found  over  both ;  in  seven  cases  it  was  over  the 
occipital  bone,  three  times  it  was  noticed  over  the  frontal,  and 
twice  over  the  temporal  (Ashby  and  Wright). 

Cephalhematoma  never  extends  beyond  the  borders  of  the 
bone  upon  which  it  is  situated. 

Symptoms. — The  tumor  usually  appears  on  the  third  or 
fourth  day  after  birth.  In  appearance  it  presents  no  discolora- 
tion of  the  surface  and  is  without  fluctuation.  In  size  it  varies 
from  that  of  a  walnut  to  that  of  a  hen's  egg.  Usually  there 
is  no  discoloration  of  the  scalp  around  its  borders.  Little  or  no 
sensitiveness  exists  in  the  tumor. 

The  swelling  usually  remains  about  a  week  after  its  appear- 


FIG.  12. — SECTION  OF  CEPHALHEMATOMA. 

ance.  For  the  first  few  days  it  continues  to  increase  in  size  and 
then  slowly  diminishes. 

A  few  days  after  its  development  a  distinct  and  well-defined 
ridge  will  be  found  at  its  circumference,  this  ridge  being  due  to 
deposits  of  bone  made  by  the  periosteum. 

Examination  of  this  ridge  may  give  the  impression  that  a  de- 
fect exists  in  the  bone  upon  which  the  tumor  occurs,  and  that 
the  tumor  is  protruding  through  a  perforation  in  the  cranium. 

After  the  decrease  and  disappearance  of  the  tumor,  the  bony 
ridge  may  remain  for  a  time,  but  finally  disappears,  leaving  no 
trace  behind. 

Pathology. — The  usual  situation  of  the  tumor  is  on  the  right 
parietal  bone  ;  a  number  of  cases,  however,  have  been  reported 
in  which  the  cephalhematoma  was  found  in  other  situations. 

Hofmohl  observed  it  to  be  bilateral  in  twenty-six  cases,  and  in 
each  of  these  the  fontanel  lay  as  a  deep  sulcus  between  the 
tumors.  A  classification  of  cephalhematoma  based  on  its  situa- 
5 


66  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

tion   has  been  made  by  various  authors.     Ashby  and  Wright 
differentiate  it  as  follows  : 

1.  Subaponeurotic,   spurious    cephal- 

hematoma, or  caput  succedaneum. 
EXTERNAL  CEPHALHEMATOMA,  c  ,       .    .     .     , 

2.  Subpenosteal,  the    true    cepnalhe- 

matoma. 

INTERNAL  CEPHALHEMATOMA,     .    .  3.  Subcranial. 
MENINGEAL  HEMORRHAGE,  ....  4.  Subarachnoid. 

It  would  seem  to  the  authors,  however,  not  only  from  their 
own  experience,  but  also  from  a  review  of  the  literature  on  the 
subject,  that  cephalhematoma  is  usually  described  as  that  form 
of  blood  tumor  beneath  the  periosteum  and  external  to  the  cran- 
ial bone — the  subperiosteal  of  the  above  classification,  and  it  is  the 
pathology  of  this  form  which  is  here  described.  Other  forms  of 
hemorrhage  within  the  cranium  belong  more  properly  under  the 
classification  of  "  intracranial  hemorrhage." 

Macroscopically,  sections  of  cephalhematoma  show  that  an 
extravasation  of  blood  has  taken  place  between  the  periosteum 
and  the  bone,  the  surface  of  the  latter  being  roughened. 

Some  thickening,  the  result  of  inflammatory  irritation,  occurs 
around  the  margin  of  the  tumor  where  the  pericranium  is  at- 
tached, and  it  is  at  this  point  that  the  shell -like  deposit  of  bone 
occurs. 

Kirk  describes  the  formation  of  these  tumors  as  follows  : 

The  principal  bones  forming  the  cranial  vault  are  developed  in 
membrane  or  fibrous  tissue.  This  membrane  later  consists  of 
two  layers,  an  external  fibrous  and  an  internal  cellular — osteo- 
genetic  or  the  true  bone-forming  layer.  If  a  thick  metal  plate 
be  inserted  beneath  the  periosteum  during  its  formation,  it  will 
soon  be  covered  by  an  osseous  deposit ;  but  if  placed  between 
the  fibrous  and  the  osteogenetic  layer,  the  plate  will  not  be 
covered  with  bone -cells,  thus  showing  that  'the  osteogenetic 
layer  is  only  capable  of  developing  bone  from  its  lower  surface. 
When  extravasation  of  blood  takes  place,  as  in  the  true  form  of 
cephalhematoma,  the  osteogenetic  layer  is  pushed  awray  from  the 
bone,  but  continues  its  power  to  develop  bone-cells,  and  this 
deposit  is  increased  around  the  area  of  limitation  of  the  tumor, 
— that  is,  the  point  at  which  the  periosteum  covering  the  tumor 
joins  that  which  covers  the  remainder  of  the  cranium, — thus 
forming  the  hard  bony  shell  which  surrounds  the  tumor. 

Diagnosis.  —  Cephalhematoma  may  be  differentiated  from 
caput  succedaneum,  hernia  of  the  brain,  craniotabes,  and  cranial 
angiomata.  From  caput  succedaneum  it  can  be  distinguished 


HEMATOMA    OF    THE    STERNOCLEIDOMASTOID.  67 

by  the  fact  that  cephalhematoma  bears  no  relation  to  the  diffi- 
culty of  the  labor  ;  on  the  contrary,  it  frequently  does  not 
appear  until  some  days  after  birth.  In  cephalhematoma  we  find 
a  fluctuating  center  to  the  tumor,  but  it  lacks  the  boggy  feel  of 
caput  succedaneum.  There  is  no  discoloration  of  the  scalp  in 
the  former,  as  would  be  found  in  the  latter.  Cephalhematoma 
also  never  crosses  a  suture,  and  is  surrounded  by  the  ring  of 
bone  before  mentioned. 

From  hernia  cerebri  it  can  be  distinguished  by  the  absence 
of  fluctuation  in  protrusions  of  the  brain.  In  hernia  there  will 
be  pulsations  which  are  synchronous  with  the  child's  heart-- 
beat. 

Hernia  also  enlarges  when  the  child  cries,  and  always  shows 
itself  between  two  bones  or  in  the  region  of  a  fontanel. 

Craniotabes  can  be  diagnosticated  by  the  softened  patches 
which  occur  in  the  skulls  of  children  affected  with  rickets ; 
these  lack  the  swelling  and  clearness  of  outline  of  a  cephalhe- 
matoma and  no  fluctuation  is  present. 

In  vascular  tumors  of  the  scalp  there  is  discoloration  of  the 
parts  and  absence  of  fluctuation  in  the  center ;  there  is  no  bony 
growth  around  the  tumor,  and  the  swelling  bears  no  relation  to 
suture  or  fontanel. 

Prognosis. — Unless  some  systemic  weakness  is  present,  the 
prognosis  is  good. 

Treatment. — In  the  largest  number  of  cases  cephalhematoma 
will  disappear  without  any  treatment  whatsoever.  In  some  in- 
stances where  the  tumor  is  not  large,  shaving  the  hair  and  paint- 
ing the  growth  with  collodion  or  some  evaporating  lotion  is  rec- 
ommended. In  regard  to  aspirating  or  opening  the  tumor,  the 
opinions  of  authors  differ  :  the  former  treatment  may  be  followed 
by  sepsis,  and  the  danger  of  severe  hemorrhage  may  present 
itself  after  incision  of  the  tumor  when  the  growth  connects  with 
an  extravasation  of  blood  inside  the  cranium. 


HEMATOMA  OF  THE  STERNOCLEIDOMASTOID. 

The  most  common  cause  of  this  tumor  is  injury  to  the  neck 
of  the  infant  following  an  attempt  at  forcible  extraction  of  the 
head  in  a  breech  presentation. 

The  danger  of  the  injury  is  increased  when  the  infant  is  par- 
tially asphyxiated,  in  which  case  the  muscles  lose  their  tone,  the 
vessels  weaken,  and  on  this  account  the  escape  of  blood  is  more 
apt  to  occur.  The  direct  cause  of  such  a  blood  tumor  is  the 


68  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

laceration  of  a  vessel  and  consequent  hemorrhage  into  the  sheath 
of  the  sternocleidomastoid  muscle  of  one  side. 

Microscopic  examination  will  show  effusions  of  blood  with 
rupture,  more  or  less  extensive,  of  the  muscular  fibers. 

Jacobi  considers  prolonged  extraction  with  forceps  a  frequent 
cause  of  this  abnormality. 

Symptoms. — The  swelling  may  appear  on  the  neck  in  from 
a  few  days  to  a  week  after  birth,  and  on  examination  a  tumor 
varying  in  size  from  that  of  a  walnut  to  that  of  a  hen's  egg  is 


FIG.  13. — HEMATOMA  OF  THE  STERNOCLEIDOMASTOID. — (From  a  patient  in  the  Philadelphia 

Poly  clinic.) 


found  in  the  upper  part  of  one  sternocleidomastoid  muscle,  the 
right  side  being  the  most  frequent  site  of  the  hemorrhage.  The 
outline  of  the  mass  is  somewhat  irregular,  and  if  existing  for 
some  time,  the  growth  may  be  cartilaginous.  The  duration  of 
the  tumor  is  from  one  to  two  months,  after  which  time  it  slowly 
disappears. 

In  some  cases  chronic  torticollis  may  result  from  such  injuries. 
Paralysis  of  the  arm  on  the  injured  side  is  occasionally  seen. 
No  especial  treatment  is  needed  in  the  majority  of  cases. 


GASTROINTESTINAL    HEMORRHAGE.  69 


UMBILICAL  HEMORRHAGE. 

Causes. — Hemorrhage  from  the  umbilicus  may  result  from 
slipping  of  a  ligature  attached  to  the  stump  of  the  cord  or  by  the 
ligature  cutting  through  the  umbilical  arteries  or  veins.  Com- 
pression of  the  vessels  by  the  ligature  may  not  be  sufficient  to 
stop  oozing  of  blood  because  of  excess  of  Wharton's  jelly,  or 
the  stump  of  the  cord  may  be  too  short  to  hold  the  ligature. 
Bleeding  from  the  navel  is  also  a  symptom  found  frequently  in 
children  suffering  from  asphyxia  or  atelectasis,  from  hemophilia, 
acute  fatty  degeneration,  acute  hemoglobinuria,  or  from  syphilis. 
Pyogenic  infection  of  the  umbilical  stump  is  also  a  frequent  cause 
of  hemorrhage. 

Treatment. — The  prophylaxis  consists  of  the  careful  tying 
of  the  cord  with  an  aseptic  ligature  after  it  has  been  washed  with 
some  suitable  antiseptic  solution.  The  treatment  of  the  stump 
consists  of  inclosing  it  in  a  mass  of  gauze  or  absorbent  cotton, 
dusted  over  with  one  part  of  salicylic  acid,  boric  acid,  or  acetanilid 
to  three  or  four  parts  of  starch  powder. 

The  stump  should  be  placed  on  its  upper  side,  with  its  dress- 
ing held  in  place  by  a  moderately  firm  abdominal  band.  When 
umbilical  hemorrhage  results  from  pathologic  causes,  such  as  have 
been  previously  mentioned,  attempts  should  be  made  to  tie  the 
bleeding  vessels  by  means  of  a  silk  ligature  or  two  sterilized  sur- 
gical pins,  the  latter  being  passed  through  the  stump  at  right 
angles  to  each  other  and  a  ligature  wrapped  around  the  pins  in 
the  form  of  a  figure  eight.  Various  styptic  applications  may  be 
indicated,  and  pressure  by  a  cotton  pad  and  tight  binder  should 
be  made. 

The  prognosis  of  umbilical  hemorrhage  resulting  from  any 
form  of  constitutional  disease  is  usually  far  from  good. 


GASTROINTESTINAL  HEMORRHAGE. 

Causes. — Hemorrhage  from  the  stomach  or  intestines  may 
arise  from  the  passage  of  blood  through  the  intestines,  blood 
having  been  swallowed  in  nursing  from  a  fissured  nipple.  Such 
blood  is  either  vomited  or  passed  through  the  bowels  as  black  or 
brownish-black  masses. 

Hemorrhage  into  the  bowel,  the  result  of  long-continued  pres- 
sure during  birth,  may  cause  evacuation  of  similar  masses  in  the 
stools. 

Perforation  of  a  blood-vessel  in  the  duodenum  through  an  in- 


7O  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

testinal  ulcer  is  a  somewhat  rare  cause  of  this  form  of  hemor- 
rhage. 

Hemophilia  may  also  be  a  cause  of  gastro-intestinal  hemor- 
rhage, and  when  originating  from  this  source,  the  bleeding  ap- 
pears in  the  first  day  or  two  of  life.  Purpura  and  syphilis  have 
also  been  given  as  causes. 

Occasionally  a  slight  bleeding  from  the  intestine  may  arise 
without  any  apparent  cause.  Possibly  this  hemorrhage  may  be 
produced  by  a  congested  condition  of  the  abdominal  organs  due 
to  the  change  in  the  circulation  at  birth. 

The  symptoms  are  those  of  internal  hemorrhage  at  any  time 
of  life.  The  child  becomes  restless,  pale,  the  extremities  are  cold 
and  the  fontanels  are  sunken.  The  child  will  vomit,  and  with 
the  vomited  matter  brownish-black  masses  of  blood  will  be 
found. 

The  same  characteristic  masses  will  be  found  in  the  discharge 
from  the  bowels.  The  abdomen  becomes  dull  and  tumid  on  per- 
cussion. 

Pathology. — In  many  cases  a  postmortem  examination  will 
reveal  nothing  but  a  simple  congestion  of  the  gastro-mtestinal 
mucous  membranes.  In  other  instances  ulceration  of  the 
stomach  or  intestines  will  be  found. 

Treatment. — The  treatment  should  be  directed  toward  check- 
ing the  hemorrhage,  when  this  is  possible.  For  this  purpose 
ergot  or  ergotin,  the  latter  in  doses  of  from  ^  to  ^  of  a  grain, 
may  control  the  bleeding.  The  drug  may  be  given  mixed  with 
simple  syrup  or  mucilage.  Tannin  or  gallic  acid  in  small  doses 
in  syrup  of  rhatany  is  advised  by  some. 

Occasionally  good  results  follow  gentle  irrigation  of  the 
bowels  with  hot  water  at  a  temperature  of  110°  F.  (43.3°  C), 
the  injection  being  given  from  a  fountain  syringe  and  containing 
a  two  per  cent,  mixture  of  creolin. 


DISEASES  CHARACTERIZED  BY  JAUNDICE. 

ICTERUS  IN  THE  NEW-BORN. 

Synonyms. — YELLOW  GROOM  ;  INFANTILE  JAUNDICE  ;  GELBSUCHT  ; 

ICTERE. 

Usually  about  the  third  to  the  fifth  day  of  life  a  certain  amount 
of  yellowish  discoloration  of  the  skin  appears.  This  first  mani- 
fests itself  in  the  face,  and  quickly  spreads  to  other  parts  of  the 


MALIGNANT   JAUNDICE    IN    THE    NEW-BORN.  7 1 

body.  It  continues  for  five  or  six  days  and  gradually  disappears. 
The  urine  during  this  time  assumes  a  saffron  color,  and  examina- 
tion will  reveal  an  excess  of  bile  pigment.  This  condition  is 
known  as  physiologic  jaundice.  It  occurs  in  from  60  to  80  per 
cent,  of  infants,  and  is  rather  more  common  in  children  born  in 
hospitals  than  in  those  seen  in  private  practice. 

Causes. — The  following  theories  have  been  ascribed  as  causes 
of  jaundice  in  the  new-born  infant : 

Following  birth  a  rapid  destruction  of  blood-corpuscles  takes 
place,  this  producing  an  excess  of  bile  pigment.  The  jaundice 
then  is  said  to  be  of  hematogenous  origin.  It  is  also  supposed 
that  a  certain  amount  of  blood  from  the  portal  vein,  owing  to  a 
patulous  condition  of  the  ductus  venosus,  passes  into  the  gen- 
eral circulation  without  being  acted  on  by  the  liver.  .  The  swell- 
ing of  Glisson's  capsule  is  also  given  as  a  cause  ;  this  swelling 
commences  at  the  umbilical  vein  and  prevents  the  discharge  of 
bile  through  the  hepatic  vessels.  Other  causes,  such  as  altera- 
tion of  the  blood  pressure  at  birth  and  congested  condition  of 
the  skin,  have  been  given. 

Symptoms  of  the  Simple  Form. — A  slight  yellowish  dis- 
coloration of  the  face  appears  about  the  third  or  fourth  day,  and 
in  the  course  of  a  few  hours  the  entire  body  assumes  a  yellowish 
tint. 

Not  infrequently  the  pigmentation  may  extend  to  a  slight  extent 
to  the  conjunctiva  or  sclerotic. 

Treatment. — No  especial  treatment  is  required  other  than 
some  mild  laxative,  such  as  a  half  teaspoonful  of  olive  or  castor 
oil  or  the  following  formula  : 

R.     Hydrarg.  chlor.  mite, gr-  tV 

Pulv.  ipecac.,      gr.  £ 

Sodii  bicarb., •  gr.  ij. 

SlG. — To  be  given  every  two  or  three  hours. 


MALIGNANT   JAUNDICE    IN   THE   NEW-BORN. 

Under  the  title  of  morbid  or  malignant  jaundice  in  the  new- 
born infant  may  be  described  the  discoloration  of  the  skin  and 
coexisting  symptoms  resulting  from  retention  in  the  blood  of 
various  bile  products.  This  retention  is  due  to  stricture,  con- 
genital or  acquired,  to  catarrh  of  the  gall-ducts  or  gall-bladder, 
duodenal  catarrh,  defective  hepatic  circulation,  asphyxia,  melena, 
Winckel's  disease,  long-continued  birth  pressure,  syphilis,  or  a 
continued  exposure  to  damp,  cold,  or  impure  atmosphere.  Jaun- 


72  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

dice  is  also  a  frequent  symptom  of  septic  infection  in  new-born 
children. 

Symptoms. — In  conjunction  with  the  symptoms  of  any  of 
the  diseases  given  as  causes,  we  find  the  ordinary  jaundice  in  the 
new-born  continuing  beyond  its  usual  period  of  duration.  These 
symptoms  are  accompanied  by  increasing  drowsiness,  subnormal 
temperature,  and  failure  to  nurse.  The  stools  are  black  and  tar- 
like.  Unless  amelioration  of  the  symptoms  occurs,  death  follows 
on  about  the  tenth  day. 

Diagnosis. — This  is  easily  made  from  the  color  of  the  skin, 
conjunctivae,  character  of  the  stools,  and,  in  the  malignant  form, 
the  general  symptoms.  Of  great  importance  is  the  differentiation 
of  the  disease  causing  it.  When  the  jaundice  arises  from  acute 
fatty  degeneration  or  from  hemoglobinuria  (Winckel's  disease), 
the  blood  changes  (see  description  of  these  diseases),  purpuric 
patches  in  the  skin,  hemorrhages,  or  cyanosis  will  aid  in  the 
diagnosis. 

When  obstruction  to  the  duct  of  the  gall-bladder  (hepatogenous 
jaundice)  produces  the  disorder,  the  discoloration  is  intense  and 
no  bile  can  be  found  in  the  stools. 

Treatment. — The  treatment  must  be  directed  to  the  cause. 
Action  of  the  ducts  and  intestine  should  be  stimulated  by  small 
doses  of  calomel  combined  with  phosphate  of  soda,  chalk,  or 
lime.  Attention  must  be  paid  to  the  skin,  to  increase  as  far  as 
possible  its  activity. 

The  infant  should  be  kept  in  a  warm,  pure  atmosphere  and 
should  be  fed  as  much  as  possible  on  breast  milk  or  the  best 
artificial  substitute  that  can  be  obtained. 

The  action  of  the  kidneys  must  be  increased  as  much  as 
possible  by  small  quantities  of  hot  boiled  water  given  regularly. 


ACUTE  HEMOGLOBINURIA  OF  THE   NEW-BORN. 
Synonym. — WINCKEL'S  DISEASE. 

This  disease  was  first  described  by  Winckel,  who  reported  the 
results  of  an  epidemic  in  which  twenty-three  cases  were  affected 
by  the  disease  in  the  Foundling  Hospital  in  Dresden,  in  1879. 
Chanin,  in  1873,  and  Bigelow,  in  1875,  also  described  this  affec- 
tion. 

Pathology  and  Symptoms. — The  disease  is  characterized 
by  a  swelling  of  Peyer's  patches  and  the  mesenteric  glands.  In 
the  cases  reported  by  Winckel  the  pyramids  of  the  kidneys 
were  colored  a  blackish  red  with  stripes  of  hemoglobin  coloring'. 


ACUTE  FATTY  DEGENERATION  OF  THE  NEW-BORN.      73 

The  liver  and  other  viscera  were  affected  by  fatty  degeneration. 
"  Hematogenic  icterus  is  present,  the  hemoglobin  being  exten- 
sively changed  into  bilirubin.  The  urine  is  reddish  brown  in 
color  and  contains  epithelial  casts,  hemoglobin,  and  micrococci." 
It  is  passed  in  small  quantities  and  after  much  straining.  The  first 
symptom  noticed  is  a  bluish  tint  of  the  face,  body,  and  limbs 
— cyanosis.  A  little  later  there  usually  appears  some  yellowish 
discoloration  of  the  skin  of  the  entire  body.  These  symptoms 
begin  about  the  fourth  day  and  progress  rapidly.  Diarrhea  and 
vomiting  soon  make  their  appearance,  and  in  a  short  time  the 
child  refuses  to  nurse.  The  duration  of  the  disease  is  usually 
about  two  days,  the  child  dying  in  convulsions  or  collapse.  The 
mortality  in  Winckel's  cases  was  nineteen  out  of  twenty-three. 


ACUTE  FATTY  DEGENERATION  IN  THE 
NEW-BORN. 

Synonym. — BUHL'S  DISEASE. 

The  cause  is  obscure,  although  in  some  instances  the  origin 
has  been  ascribed  to  a  condition  of  lowered  vitality  in  the  mother 
during  pregnancy.  Apparently  the  disease  begins  in  the  latter 
portion  of  gestation.  Asphyxia  has  been  given  by  some  as  a 
probable  cause  and  by  others  as  a  result  of  the  disease. 

Pathology. — The  pathologic  changes  seem  to  consist  of  a 
general  parenchymatous  inflammation  of  all  the  organs.  Small 
hemorrhagic  patches  are  found  in  the  various  viscera,  and  some 
of  these  organs  are  found  infiltrated  with  blood  and  bile.  Micro- 
scopic examination  of  the  tissues  of  the  various  internal  organs, 
and  particularly  of  the  liver,  kidneys,  and  heart,  will  show  a  state 
of  acute  fatty  degeneration. 

Symptoms. — The  disease  usually  appears  in  from  the  first 
to  the  sixth  day  of  life,  the  child  becoming  jaundiced  or  pale. 
Hemorrhages  occur  from  the  intestines  or  umbilicus.  Petechial 
patches  will  be  found  under  the  skin  and  mucous  membranes, 
particularly  that  of  the  mouth.  Actual  hemorrhages  may  also 
take  place  from  the  various  mucous  surfaces.  There  is  more  or 
less  cyanosis,  and  actual  asphyxia  may  be  produced  by  fat  emboli 
being  washed  into  the  pulmonary  circulation.  Dropsy,  general 
or  local,  will  be  seen  in  many  cases. 

The  treatment  consists  of  stimulating  the  patient  as  much  as 
possible  and  checking  the  hemorrhage ;  for  the  latter  purpose  ergot 
or  tannic  acid  in  suitable  doses  is  to  be  given.  In  the  majority 
of  cases  the  child  dies  notwithstanding  all  our  efforts  in  its  behalf. 


74  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 


DISEASES    PRODUCED    BY    SEPTIC    INFECTION. 

GENERAL    SEPTIC    INFECTION    OF    THE 
NEW-BORN. 

Septic  infection  in  the  new-born  may  arise  either  from  ante- 
partum  or  postpartum  causes.  The  most  frequent  causative 
factor  is  the  entrance  of  infective  micro-organisms  through  the 
granulating  surface  left  by  the  stump  of  the  umbilical  cord  after 
the  latter  has  fallen  off.  From  this  origin  an  inflammation  of 
the  arteries  and  veins  results,  and  subsequently  thrombi  and 
infiltration  of  the  surrounding  tissues  follow.  The  infection 
usually  travels  along  the  course  of  the  umbilical  arteries  within 
the  abdomen,  and  later  frequently  involves  the  bladder  and 
tissues  immediately  surrounding  it.  During  the  progress  of  the 
infection  within  the  body  the  umbilical  scar  may  remain  open, 
or,  as  is  not  uncommonly  found,  may  close  and  heal,  there  being 
nothing  left  but  a  small  ring  of  inflammation  surrounding  it. 
Weber  and  Runge  have  pointed  out  that  in  those  cases  in  which 
infection  has  occurred  through  the  umbilicus  the  tissue  around 
the  artery  is  first  involved  after  the  infection  has  traveled  within 
the  abdomen.  The  iliac  vessels  and  retroperitoneal  connective 
tissue  are  usually  not  attacked. 

As  a  result  of  general  septic  infection  peritonitis  and  metas- 
tatic  abscesses  may  appear  in  the  abdominal  viscera,  or  the  joints 
may  become  involved  and  arthritis  follow.  In  two-fifths  of  the 
reported  cases  Runge  observed  pneumonia  or  pleurisy  followed 
by  small  metastatic  abscesses. 

When  the  case  has  a  fatal  termination,  death  usually  results 
from  pneumonia  or  pleurisy,  although  pericarditis  is  not  an 
uncommon  cause. 

Symptoms. — In  antepartum  sepis,  in  those  cases  in  which 
the  child  is  born  alive,  death  usually  occurs  in  a  few  days  from 
interstitial  pneumonia  or  fatty  degeneration.  When  the  child 
dies  before  birth,  the  skin  will  be  found  macerated  and  effusions 
of  bloody  serum  occur  in  various  cavities  of  the  body.  Patches 
of  ecchymosis  will  be  seen  in  the  peritoneum,  pericardium,  and 
pleura. 

The  symptoms  of  postpartum  infection  usually  begin  with 
a  ring  of  inflammation  around  the  umbilicus ;  this  is  often  fol- 
lowed by  ulceration  (omphalitis).  In  quite  a  number  of  cases 
this  inflammation  may  subside  and  the  umbilical  scar  will  appear 
to  be  partially  or  completely  healed.  The  infant  will,  however, 
have  a  fever  ranging  from  101°  F.  to  103°  F.  Anorexia  appears 


GENERAL    SEPTIC    INFECTION    OF    THE    NEW-BORN.  75 

and  the  child  refuses  to  nurse.  The  usual  jaundice  following 
birth,  instead  of  disappearing  on  the  third  or  fourth  day,  will 
continue  to  increase,  the  stools  remaining  dark  and  tar-like. 
Some  distention  of  the  abdomen,  with  general  symptoms  of 
peritonitis,  soon  manifest  themselves,  the  child  holding  its  legs 
and  thighs  constantly  flexed.  The  breathing  is  thoracic  in 
character  and  is  rapid.  In  some  cases  ulceration  of  the  mouth, 
pharynx,  intestines,  bones,  or  joints  may  be  observed.  Emacia- 
tion is  rapid  and  progressive  ;  vomiting  and  diarrhea  sometimes 
appear.  The  inflammation  of  the  larynx  may  result  occasionally 
in  actual  croup  (septic  croup). 

When  death  occurs,  the  immediate  cause  is  usually  convulsions 
or  exhaustion,  pleurisy,  or  pneumonia. 

The  prognosis  in  septic  infection  of  the  new-born  is  distinctly 
bad. 

Treatment. — The  best  preventive  treatment  of  septic  in- 
fection in  the  new-born  lies  in  the  careful  attention  to  the  umbili- 
cus from  the  moment  of  section  of  the  umbilical  cord  until  the 
time  that  it  has  fallen  off  and  the  wound  is  completely  healed. 
It  should  be  remembered  that  the  site  of  the  umbilical  cord  is 
always  an  absorbing  surface,  through  which  septic  micro-organ- 
isms may  gain  entrance  to  the  child's  body,  and  therefore  as  much 
care  should  be  directed  to  the  antiseptic  dressing  of  the  cord- 
stump  as  would  be  exercised  in  dressing  any  other  wound. 
During  the  process  of  mummification  of  the  cord-stump  it  should 
be  kept  covered  with  some  drying  antiseptic  powder.  It  is  of 
great  importance  that  the  cord-stump  should  be  kept  dry. 
When  a  drop  or  two  of  pus  appears  in  the  umbilicus  after  sepa- 
ration of  the  cord-stump,  the  folds  of  the  umbilical  scar  should 
be  carefully  mopped  out  with  a  saturated  solution  of  boric  acid 
or  hydrogen  peroxid,  applied  on  a  small  piece  of  cotton. 

The  superiority  of  the  latter  antiseptic  lies  in  the  readiness 
with  which  it  passes  between  all  the  folds  and  crevices  of  the 
umbilicus  and  removes  all  foci  of  infection. 

Intra-uterine  infection  should  be  guarded  against  as  far  as 
possible  by  careful  attention  to  the  mother's  health  during  ges- 
tation. Various  constitutional  diseases,  such  as  syphilis  or 
gonorrhea,  should  be  suitably  treated,  and  all  sources  of  infec- 
tion from  irritating  vaginal  discharges  should  be  removed  by  the 
use  of  antiseptic  douches  and  cleansing  the  external  genitals 
during  the  last  week  of  pregnancy.  The  constitutional  treatment 
of  an  infant  suffering  from  septic  fever  is  the  same  as  the  treatment 
of  sepsis  in  the  adult,  remembering,  of  course,  the  age  of  the 
patient.  The  high  temperature  should  be  reduced  by  cool 


76  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

sponging  and  possibly  some  alcohol,  the  latter  in  doses  suitable 
for  the  age  and  condition  of  the  child.  Minute  doses  of  strych- 
nin and  quinin  are  also  of  use. 


OMPHALITIS. 

Definition. — An  inflammation  of  the  navel  itself  or  of  the 
surrounding  parts. 

Cause. — In  the  majority  of  cases  omphalitis  is  of  septic  origin, 
although  occasionally  its  cause  may  be  doubtful.  Syphilis  is  a 
frequent  cause.  It  may  confine  itself  to  the  umbilicus  and  im- 
mediately surrounding  tissues,  or  may  spread  and  involve  nearly 
the  whole  of  the  abdominal  wall,  either  superficially  or  through- 
out its  entire  thickness.  The  disease  begins  in  the  second  or 
third  week  after  birth  and  may  continue  for  some  time.  Unless 
the  inflammation  extends  to  the  peritoneum,  the  prognosis  is 
fairly  good.  In  some  perfectly  normal  infants  separation  of  the 
cord  is  followed  by  a  slight  irritation  ;  this  is  particularly  the 
case  where  undue  friction  or  any  form  of  local  irritant  has  been 
applied.  This  condition  is  known  as  excoriation  of  the  navel. 

Occasionally  after  detachment  of  the  cord  a  serous  dis- 
charge is  noticed  ;  this  may  exist  for  some  time  and  is  known  as 
blennorrhagia.  The  site  of  the  umbilicus  may  also  be  affected 
by  a  croupous  or  diphtheric  exudate. 

The  treatment  of  all  these  forms  of  inflammation  of  the 
umbilicus  consists  of  absolute  cleanliness  and  attention  to  the 
rules  for  prevention  before  mentioned.  When  abscesses  form, 
they  should  be  opened  and  treated  antiseptically. 

TETANUS  IN  THE  NEW-BORN. 

Cause. — Tetanus  in  early  life,  like  the  disease  in  adults,  is 
produced  by  infection  with  the  tetanus  bacillus.  The  usual  site 
of  entrance  is  the  umbilicus  before  the  scar  is  completely  healed. 
Soiled  dressings  or  general  uncleanliness  are  the  means  of  trans- 
mission. The  disease  usually  appears  about  the  ninth  day  of 
life;  hence  the  name  "nine-day  fits"  has  occasionally  been 
applied  to  the  disease.  It  may  not,  however,  appear  until  the 
fifteenth  day,  which  has  been  described  by  West  as  the  limit  at 
which  we  usually  see  the  disease.  Cases  have  been  reported  as 
early  as  the  third  day. 

Tetanus  in  infancy  may  occur  in  any  part  of  the  world,  the 
largest  number  of  cases  being  found  in  warm  climates.  It  may 
arise  sporadically  or  in  epidemics  ;  thus  we  have  reports  of  the 


INSPIRATION    PNEUMONIA.  77 

serious  epidemics  occurring  in  the  island  of  St.  Kilda,*  and  of 
that  occurring  in  the  island  of  Heimacy,  off  the  coast  of  Ice- 
land, which  took  place  early  in  the  present  century,  f  It  seems 
probable  that,  as  the  knowledge  of  the  use  of  antisepsis,  espe- 
cially as  applied  to  the  dressing  of  the  cord-stump  in  new-born 
infants,  is  understood  and  practised  throughout  the  world,  these 
epidemics  of  tetanus  neonatorum  will  decrease  or  almost  dis- 
appear. The  value  of  the  antiseptic  dressing  of  the  umbilicus 
was  clearly  demonstrated  in  the  epidemic  occurring  on  the  island 
of  St.  Kilda,  where  the  mortality  of  cases  occurring  previous  to 
the  introduction  of  asepsis  was  100  per  cent.  ;  the  number  of 
cases  affected  decreased  after  its  introduction  to  nil. 

Symptoms. — The  first  phenomenon  noticed  is  inability  to 
nurse  because  of  spasms  of  the  muscles  of  the  jaw  and  face 
generally ;  this  is  known  as  trisnms.  The  facial  spasm  is  soon 
followed  by  a  similar  condition  arising  all  over  the  body,  the 
attacks  increasing  rapidly  in  severity  and  length  of  continuance. 
The  face  has  the  peculiar  expression  described  under  the  name 
of  "  risus  sardonicus."  There  is  also  frequently  associated  with 
the  disease  a  peculiar  whining  cry.  The  climax  of  the  malady 
is  generally  reached  in  twelve  hours,  and  when  the  child  dies,  it 
is  in  spasms  or  coma.  The  convulsions,  like  those  of  tetanus  in 
the  adult,  are  increased  by  cold  or  by  noises.  The  entire  course 
of  the  disease  is  usually  about  two  days. 

The  prophylactic  treatment  consists  of  observing  the  rules 
before  mentioned  in  dressing  the  cord.  For  the  treatment  of 
the  convulsions  hydrate  of  chloral,  chloroform,  and  alcoholic 
stimulants  give  the  best  results.  Opium,  cannabis  indica,  bella- 
donna, and  bromid  of  potassium  have  been  recommended.  Warm 
baths  and  ice  applied  to  the  spine  have  occasionally  been  of  use. 
The  prognosis  is  exceedingly  grave. 

INSPIRATION  PNEUMONIA. 

This  disease  is  usually  caused  by  inspiratory  efforts  on  the  part 
of  the  child,  due  to  pressure  on  the  umbilical  cord  during  a  pro- 
longed labor.  It  is  most  commonly  found  in  those  cases  in  which 
the  vaginal  secretions  of  the  mother  have  been  rendered  septic 
by  a  preexisting  gonorrhea  or  endometritis. 

The  type  of  pneumonia  is  usually  lobular,  and  is  very  dangerous 
to  life.  The  treatment  should  be  prophylactic,  care  being  taken 

*  Turner,  "Glasgow  Med.  Jour.,"  1895,  No.  3,  p.  161. 
f  Snowman,  "Brit.  Med.  Jour.,"  1895,  vol.  n,  p.  132. 


78  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

that  the  vaginal  secretion  in  the  mother  is  rendered  aseptic  by 
douches.  It  must  be  remembered  in  the  treatment  of  this  disease 
that  the  condition  is  of  septic  origin,  and  therefore  the  principal 
indications  are  to  sustain  the  patient  by  the  use  of  tonics,  alco- 
hol, etc.  Locally,  the  lung  conditions  should  be  treated  as  any 
other  form  of  pneumonia. 


SCLEREMA. 

Definition. — By  the  term  sclerema  we  understand  a  hardening 
of  the  skin  and  subcutaneous  cellular  tissue  and  fat.  The  con- 
dition is  accompanied  by  a  lowering  of  bodily  temperature. 

Causes. — Sclerema  may  be  congenital  or  acquired  ;  in  the 
latter  case  it  is  most  frequent  in  feeble  children — those  prema- 
turely born  or  who  are  syphilitic.  It  frequently  follows  ex- 
hausting diseases,  such  as  various  forms  of  diarrhea.  The  disease 
is  most  commonly  found  in  hospitals  and  foundling  asylums, 
particularly  where  many  children  are  crowded  together.  It  is 
more  common  in  Europe  than  in  America.  The  principal  cause 
would  appear  to  be  extreme  feebleness  with  continued  lowering 
of  the  temperature,  and,  in  consequence,  a  hardening  of  the  sub- 
cutaneous fat.  Atelectasis  is  frequently  an  accompanying  con- 
dition. 

Symptoms. — The  first  symptom  noticed  is  the  hardening  of 
the  skin,  which  usually  begins  in  the  lower  extremities  and 
spreads  upward,  affecting,  in  the  order  given,  the  trunk,  the  upper 
extremities,  and  the  face.  It  is  especially  marked  in  the  thighs, 
buttocks,  back,  and  cheeks.  The  hardening  may  be  universal  or 
affect  only  circumscribed  areas.  The  skin  may  be  smooth  or 
lobulated.  The  skin  changes  to  a  dirty  yellow  or  bluish-yellow 
color,  is  hard,  does  not  pit  on  pressure,  and  seems  to  be  closely 
attached  to  the  subcutaneous  tissue.  The  surface  of  the  body 
and  even  the  mucous  membrane  of  the  mouth  feel  cold  and 
stone-like.  The  bodily  temperature  is  much  reduced,  falling 
often  to  92°  to  96°  F.  (33.3°  to  38.6°  C).  The  respiration  is 
slow  and  embarrassed.  Circulation  is  poor. 

Pathology. — The  pathologic  changes  are  in  many  cases  ob- 
scure. In  a  case  reported  by  J.  W.  Ballantyne  there  was  found, 
on  microscopic  examination,  to  be  an  increase  in  the  number  and 
size  of  the  connective-tissue  bundles  and  an  atrophy  of  the 
adipose  tissue.  Northrup  reports  a  typical  case  in  which  no 
abnormal  changes  were  found  in  the  skin.  Langer  and  others 
believe  that  solidification  of  the  fatty  tissues,  in  consequence  of 
the  very  low  temperature,  is  the  cause  of  the  hardening  of  the 


MELENA    IN    THE    NEW-BORN.  79 

skin.  It  has  also  been  suggested  that  in  some  cases  the  causes 
are  very  much  the  same  as  those  producing  myxedema.  In 
many  of  these  patients  a  postmortem  examination  will  reveal  an 
edema  of  the  subcutaneous  tissues,  the  secretion  frequently  being 
changed  into  jelly-like  masses.  Serous  effusions  into  the  pleura 
sometimes  occur. 

Diagnosis. — The  only  condition  with  which  sclerema  is  likely 
to  be  confounded  is  that  of  general  edema,  from  which  it  may 
be  differentiated  by  the  fact  that  in  sclerema  there  is  no  pitting 
of  the  skin  on  pressure,  by  the  rigid  condition  of  the  body,  and 
by  the  great  reduction  in  temperature. 

Prognosis. — The  prognosis  is  bad  in  nearly  every  case,  the 
disease  generally  ending  fatally  in  from  one  to  four  days. 

Treatment. — The  treatment  consists  of  improving,  as  much 
as  possible,  the  hygienic  surroundings  of  the  child,  giving  mas- 
sage, galvanism,  and  also  alcoholic  stimulants  in  moderate  doses. 
Such  drugs  as  strychnin,  camphor,  musk,  malt,  and  general 
tonics  have  been  recommended.  The  administration  of  lanolin 
internally  has  been  recommended.  Thyroid  extract  has  been 
said  to  be  of  service.  When  possible,  the  infant  should  be  fed 
by  a  wet-nurse,  or,  if  it  can  not  suck,  the  milk  must  be  pepton- 
ized  and  given  by  the  rectum,  or  the  child  may  be  fed  by  a 
medicine  dropper  inserted  far  back  in  the  mouth.  The  bodily 
heat  is  to  be  maintained  by  keeping  the  child  in  an  incubator  at 
a  fairly  high  temperature. 

MELENA  IN  THE  NEW-BORN. 

Definition. — A  malignant  form  of  hemorrhage  from  the 
stomach  or  intestines,  occurring  in  the  new-born. 

Causes. — The  hemorrhage  may  be  due  to  a  gastric  or  enteric 
ulcer ;  to  thrombosis  resulting  from  embolism  in  the  vessels  of 
these  organs.  Congenital  weakness  of  the  vessels  of  the 
stomach  or  duodenum  and  persistence  of  the  ductus  arteriosus 
have  been  ascribed  as  causes. 

Symptoms. — The  symptoms  are  vomiting  of  blood  or  its 
passage  in  the  stools.  This  condition  is  accompanied  by  rapid 
loss  of  flesh,  failure  to  nurse,  and  continued  hemorrhage,  until 
the  child  dies  of  collapse.  The  attack  usually  lasts  from  one 
day  to  a  week.  While  the  prognosis  is  grave,  cases  occasionally 
recover. 

Treatment. — The  treatment  consists  of  the  use  of  warm 
antiseptic  rectal  irrigations,  and  the  administration,  by  the  mouth, 
of  ergot  or  some  astringent  remedy. 


8O  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

MASTITIS  IN  THE  NEW-BORN. 

It  is  a  common  occurrence  to  notice  a  secretion  of  milk  in  the 
breasts  of  the  new-born  infant.  This  secretion  is  equally  frequent 
in  males  and  females.  The  quantity  of  milk  secreted  varies  from 
a  few  drops  to  probably  a  dram  or  more  in  exceptional  cases. 
The  milk  secreted  resembles  colostrum,  and  by  analysis  has  been 
shown  to  be  composed  of  fat,  sugar,  proteids,  salts,  and  water. 
It  is  often  termed  "  witch's  milk."  The  occurrence  of  this 
secretion  is  of  very  little  importance,  and  usually  ceases  after 
ten  or  fifteen  days,  the  secretion  being  most  active  from  the 
eighth  to  the  fifteenth  day.  The  breasts  show  all  the  phenomena 
of  physiologically  active  organs.  Should  the  secretion  be  abun- 
dant, it  can  usually  be  dried  up  by  painting  the  breasts  with  the 
tincture  of  belladonna.  Strictly  antiseptic  washes  with  com- 
presses may  answer  the  same  purpose.  Undue  pressure  or  slight 
trauma  from  careless  or  rough  handling  may  cause  the  breasts 
to  become  inflamed,  and  thus  set  up  a  mastitis  which  may  be 
more  or  less  severe  and  even  terminate  in  an  abscess. 

Mastitis  is  a  rare  condition  in  infants,  but  it  is  occasionally 
seen  and  may  lead  to  fatal  results.  The  predisposing'  cause  is 
the  congestion  which  accompanies  the  active  organ.  The  ex- 
citing cause  is  a  trauma,  micro-organisms  gaining  entrance  to 
the  breasts  through  abrasions  or  fissures  produced  by  the  trauma, 
or  even,  according  to  some  authorities,  through  the  milk-ducts. 
The  affection  is  often  due  to  a  want  of  cleanliness.  The  symp- 
toms are  the  usual  ones  seen  in  inflammation  of  the  breasts. 
Should  the  condition  progress  to  suppuration,  extensive  slough- 
ing may  take  place,  as  shown  in  a  case  reported  by  Bush, 
although  a  single  abscess  is  the  more  frequent  result.  The 
child  is  restless,  there  is  a  steady  loss  of  weight,  due  to  the 
fact  that  the  child  refuses  to  nurse,  is  peevish,  fretful,  and 
suffers  from  insomnia.  The  parts  should  be  kept  clean  and 
no  one  allowed  to  press  the  breasts.  A  small  cotton  compress 
may  be  used  for  their  protection. 

In  case  acute  inflammation  develops,  it  should  be  treated  as 
any  inflammatory  process.  Hot  antiseptic  fomentations  may  be 
used  in  the  beginning  ;  should  pus  form,  incise  and  drain.  Keep 
up  the  child's  strength  with  general  stimulants  and  tonics. 


OBSTETRIC    PARALYSIS.  8  I 


OBSTETRIC  PARALYSIS. 

Definition. — A  form  of  paralysis  of  the  central  or  peripheral 
nerves  occurring  in  the  new-born  and  usually  following  prolonged 
efforts  at  forceps  or  manual  extraction,  or  from  other  injuries  to 
the  head  or  extremities  during  birth. 

Causes. — The  most  frequent  cause  is  attempts  at  using  the 
forceps  as  a  means  of  compression  or  forcible  rotation  to  the 
fetal  head  instead  of  using  the  instrument  as  a  tractor  only. 
Occasionally,  after  delivery  of  the  shoulder  in  a  presentation  by 
the  breech  or  vertex,  prolonged  traction  made  by  hooking  the 
fingers  in  the  axillae  will  result  in  injury  to  the  brachial 
plexus.  One  or  more  nerve-trunks  may  suffer  traumatism,  and 
from  this  will  arise  a  form  of  paralysis  of  the  arm  known  as 
Duchenne's  paralysis.  A  very  common  form  of  peripheral 
paralysis  is  that  known  as  "  Erb's  paralysis,"  or  "  the  upper-arm 
type  of  paralysis."  This  arises  from  injury  to  the  fifth  and  sixth 
cervical  nerves.  The  muscles  affected  are  the  trapezius  and,  to 
a  greater  extent,  the  deltoid,  biceps,  brachialis  anticus,  supinator 
longus,  or  the  supraspinatus  or  infraspinatus.  Any  or  all  of 
these  muscles  may  be  involved. 

In  a  number  of  cases  the  violent  separation  of  the  head  from 
the  shoulders  and  the  consequent  stretching  of  the  plexus  at  the 
junction  of  the  fifth  and  sixth  roots  of  the  brachial  plexus  may 
be  a  cause,  as  has  been  pointed  out  by  Walton,  Carter,  and 
others.  The  first-named  author  gives  as  his  opinion  that  in 
most  of  these  cases  the  plexus  is,  during  labor,  already  brought 
against  the  clavicle,  rotation  of  the  head  away  from  the  affected 
side  takes  place,  and  at  the  same  time  the  suprascapular  nerve  is 
put  on  the  stretch  between  the  point  of  its  emergence  and  the 
bony  edge  around  which  it  passes  to  reach  the  infraspinous  fossa. 
As  the  head  separates  from  the  shoulders  after  rotation  has 
occurred,  the  shoulder  being  firmly  held  at  the  brim  of  the 
pelvis,  its  suprascapular  nerve  is  stretched  still  further  and  the 
plexus  bruised  against  the  clavicle.  As  additional  evidence  in 
favor  of  his  view  the  author  calls  attention  to  the  fact  that  the 
right  arm  is  generally  affected  in  left  occipito-anterior  and  right 
occipitoposterior  positions  and  presentations,  while  paralysis  of 
the  left  arm  is  most  generally  seen  in  those  cases  where  the 
position  and  presentation  have  been  right  occipito-anterior. 

When  facial  paralysis  occurs,  it  is  usually  due  to  pressure  by 
the  forceps  upon  the  seventh  nerve  at  its  point  of  exit  from  the 
stylomastoid  foramen.  This  form  of  paralysis,  although  occa- 
sionally permanent,  usually  disappears  in  from  a  few  days  to  a 
6 


82  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

week  or  two  after  birth.  A  much  graver  and  more  lasting  form 
of  paralysis  is  apt  to  occur  from  injury  to  the  brachial  plexus  in 
the  manner  before  described.  The  pressure  upon  the  cords  of 
this  plexus  may  either  occur  in  the  axillae,  or,  as  Ross  has  dem- 
onstrated, the  fifth  cranial  nerve  may  be  easily  injured  by  a  grip 
of  the  blade  upon  the  upper  arm  and  clavicle  at  a  point  where 
the  nerve  descends  over  the  transverse  processes  of  the  fifth  and 
sixth  cervical  vertebrse.  Lane  has  also  reported  a  case  of  injury 
to  the  brachial  plexus  by  forceps — the  face  and  arm  were  para- 
lyzed. On  postmortem  examination  a  clot  of  blood  was  found 
at  the  stylomastoid  foramen  and  around  the  cords  of  the  brachial 
plexus. 

Paralysis  of  central  origin  following  labor  may  arise  from  pres- 
sure by  blood-clot  ;  thus,  Lihotzky  has  reported  cases  in  which 
pressure  arose  from  this  cause,  probably  induced  by  fracture  of 
the  orbital  ridge  by  forceps.  Hirst  has  reported  a  case  of  lacer- 
ation of  one  of  the  sinuses  of  the  dura  mater  caused  by  the 
overlapping  of  the  parietal  bones  during  labor.  Precipitate  labor, 
following  which  the  child  has  fallen  to  the  ground,  has  been 
given  as  a  cause  of  paralysis  in  the  new-born.  Instances  of 
cerebral  atrophy  with  hemiplegia,  either  alone  or  associated  with 
sensory  and  mental  debility,  and  accompanied  by  frequent  epilep- 
tiform  convulsions,  due  in  many  cases  to  birth  lesions,  are 
reported  by  Allen  Starr  and  others  ;  other  instances  of  the  late 
effects  of  forceps  compression  have  been  reported  by  Osier,  who, 
in  the  records  of  the  Philadelphia  Infirmary  for  Nervous  Dis- 
eases, found  nine  cases  following  instrumental  delivery.  Six  of 
these  had  histories  of  direct  injury  by  forceps,  and  some  of  them 
had  marks  on  the  head  existing  since  birth.  In  all  of  these  cases 
the  paralysis  appeared  gradually  a  short  time  after  birth. 

Symptoms. — When  paralysis  of  the  arm  or  leg  is  present, 
there  will  be  deficiency  or  absence  of  motion  in  the  parts  affected, 
and  in  a  short  time  the  muscles  will  appear  soft  and  flabby,  unless 
for  a  time  masked  by  the  abundant  superficial  fat.  More  or  less 
complete  anesthesia  will  be  noticed.  If  the  paralysis  is  of  a 
mild  type,  recovery  generally  sets  in  early  and  may  be  complete. 
If  severe,  and  the  case  remains  in  about  the  same  condition  for 
a  long  time,  the  chances  for  recovery  are  less  favorable.  As  the 
peripheral  nerves  are  not  developed  until  several  weeks  after 
birth,  any  injury  to  them  prevents  their  ever  attaining  functional 
competence.  The  response  to  electric  tests  varies  with  the 
degree  and  nature  of  the  lesion  ;  if  it  can  not  be  excited  or  if 
the  reaction  shows  the  anodal  closure  contraction  to  be  greater 
than  the  cathodal  contraction,  then  there  is  little  hope.  While 


OBSTETRIC    PARALYSIS.  83 

the  paralysis  is  usually  confined  to  one  nerve  or  one  limb,  it 
may  be  bilateral  when  the  injury  extends  to  both  sides.  If  the 
face  is  involved,  the  first  symptom  generally  noticed  is  a  lack 
of  movement  of  the  facial  muscles  of  one  side  ;  in  some  cases 
one  eye  may  be  injured,  and  drooping  of  the  eyelid,  contraction 
of  the  pupil,  or  retraction  of  the  eyeball  will  be  present ;  lack 
of  expression  on  the  injured  side  of  the  face  and  irregularity  of 
the  mouth  will  complete  the  picture. 

Diagnosis. — Although  paralysis  due  to  causes  incident  to 
birth  is  generally  easily  diagnosticated,  yet  occasionally,  from  a 
medicolegal  aspect,  as  well  as  that  of  the  possible  outcome  of 
the  case,  it  becomes  necessary  to  consider  certain  points  of 
differentiation.  In  cases  of  severe  injury  following  the  use  of 
forceps,  especially  when  compression  has  been  used,  a  depressed 
spoon-  or  funnel-shaped  mark  will  commonly  be  found  on  the 
areas  of  the  fetal  skull  which  have  been  within  the  grasp  of  the 
forceps.  Occasionally  these  will  be  bounded  by  a  well-defined 
ridge.  The  most  common  sites  for  these  marks  are  the  orbital 
and  parietal  regions  and  at  the  parieto-occipital  junction.  As  a 
point  of  differentiation  from  the  above,  Fritsch  has  described  the 
characteristic  injury  of  the  head  received  in  falling  after  precipi- 
tate birth  as  follows:  "The  fracture  begins  in  a  suture  and 
extends  outward  to  the  middle  of  the  bone.  Usually  there  is 
but  one  fissure,  which  ends  where  the  bone  is  thickest.  The 
parietal  bone  is  the  one  most  often  injured,  and  the  fissure  usu- 
ally ends  in  the  parietal  eminence."  When  the  brachial  plexus 
is  injured,  the  paralysis  affects  but  one  arm,  and  will  generally 
appear  very  soon  after  birth  ;  usually  while  washing  the  child 
the  nurse  will  observe  that  it  moves  but  one  arm,  while  the  other 
hangs  uselessly  by  its  side.  On  examination,  no  evidences  of  a 
fracture  of  the  bone  will  be  found,  and  passive  movement  of  the 
arm  causes  little  or  no  pain.  The  paralysis  is  not  generally  fol- 
lowed by  contraction.  Electricity  will  frequently  be  found  to  be 
of  use  in  determining  the  injury  :  when  the  nerve  is  but  slightly 
injured,  there  will  be  more  or  less  response  to  the  faradic 
current ;  but  if  the  injury  be  great,  there  will  be  little  or  no  re- 
sponse. 

Prognosis. — The  prognosis  of  facial  palsy  of  simple  form,  and 
not  the  result  of  intracranial  hemorrhage  or  fracture,  is  good. 
The  muscles  usually  assume  their  activity  at  the  end  of  a  few 
weeks.  When  traumatism  has  occurred  to  the  large  nerve-trunks 
or  laceration  has  resulted,  or  when  the  nerves  have  been  injured 
to  a  large  extent,  the  paralysis  will  be  slow  in  disappearing  and 
permanent  injury  may  result. 


84  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

Treatment. — The  treatment  of  injuries  of  the  nerves  of  the 
new-born  may  be  divided  into  prophylactic  and  curative. 

The  prophylaxis  requires  the  careful  study  of  every  case  of 
delivery.  By  the  accurate  use  of  abdominal  palpation  and  aus- 
cultation the  position  of  the  child  in  utero  must  be  made  out  and 
the  relative  size  of  the  fetus  to  the  birth  canal  through  which  it 
must  pass  should  be  determined. 

While  the  judicious  use  of  the  forceps  to  aid  the  expulsive 
forces  of  the  uterus  is  fully  justifiable,  yet  long-continued  traction 
or  the  high  application  of  the  forceps  without  axis  traction  can 
not  be  too  strongly  condemned.  It  is  utterly  useless  and  very 
dangerous  to  both  mother  and  child  to  attempt  to  drag  a  fetus 
through  a  birth  canal  which  is  too  small  for  it,  and  efforts  to  do 
this  will  be  followed  by  nothing  but  disaster. 

When,  after  a  carefully  made  diagnosis,  including  the  measure- 
ment of  at  least  the  conjugate  of  the  pelvic  inlet,  it  is  found  that 
the  child  is  too  large  to  pass,  or,  inversely,  that  the  mother's  parts 
are  too  small,  operative  procedures  must  be  resorted  to — either 
the  Cesarean  operation  or  symphysiotomy,  and  for  the  choice  of 
these  the  student  is  referred  to  the  text-books  on  obstetrics. 

In  cases  where  an  infant  is  born  with  symptoms  of  cerebral 
compression  following  forceps  delivery,  the  treatment  by  sur- 
gical means  may  be  considered  and  the  depressed  bone  ele- 
vated. 

When  injury  to  the  brachial  plexus  has  occurred,  the  treatment 
should  consist  of  rest  for  the  injured  arm  and,  later,  passive 
exercise.  When  the  arm  itself  is  injured,  it  should  be  wrapped 
in  cotton  batting  and  fixed  to  the  side,  care  being  taken  that  in 
bathing  or  dressing  the  child  the  arm  is  not  allowed  to  hang 
down,  as  by  so  doing  the  injuries  to  the  nerves  maybe  increased. 
Tight  bandages  must  be  avoided.  At  the  end  of  four  or  five 
weeks  the  muscles  may  be  treated  by  massage,  shampooing,  and 
galvanism. 

As  the  progress  of  these  cases  is  at  best  very  slow,  treatment 
must  not  be  discontinued  so  long  as  any  improvement,  no  matter 
how  slight,  continues.  Massage  and  electricity  do  much  good 
in  these  cases. 

UMBILICAL  POLYPI. 

Polypoid  granulations  around  the  umbilicus  occasionally  ap- 
pear and  cause  an  oozing  of  blood.  The  treatment  should  con- 
sist of  cleanliness  and  the  application  of  some  antiseptic,  such 
as  peroxid  of  hydrogen  in  a  spray  and  solutions  of  silver  nitrate. 

The  prognosis  is  generally  favorable. 


DIVERTICULUM    TUMOR. 


DIVERTICULUM  TUMOR  AND  PERSISTENCE  OF  THE 
OMPHALOMESENTERIC  DUCT. 

Owing  to  the  imperfect  obliteration  of  the  vitelline  or  omphalo- 
mesenteric  duct  during  fetal  life  there  may  arise  a  number  of 
abnormalities,  among  which  are  Meckel's  diverticulum  and  a 
patulous  condition  of  the  omphalomesenteric  duct.  The  former 


a 


FIG.  14. — DIAGRAM  ILLUSTRATING  THE  EFFECTS  OF  THE  PERSISTENCE  OF  THE  OMPHALO- 
MESENTERIC DUCT  AND  THE  FORMATION  OF  THE  SO-CALLED  DIVERTICULUM  TUMOR. 
— (Riesman.) 

appears  as  a  blind  pouch  on  the  convex  surface  of  the  lower  part 
of  the  ileum,  and  may  occasionally  extend  to  the  umbilicus. 
The  omphalomesenteric  duct  exists  as  an  open  cylindric  tube  lead- 
ing from  the  umbilicus  to  the  ileum.  (See  a,  b,  Fig.  14.)  Both 
the  diverticulum  and  the  duct  are  lined  with  mucous  membrane 
similar  to  that  of  the  ileum.  When  the  diverticulum  or  duct 
connects  with  the  umbilical  opening,  the  mucous  membrane  of 


86  DISEASES    OCCURRING    AT    OR    NEAR    BIRTH. 

the  duct  becomes  continuous  with  the  skin  at  the  navel  and  con- 
sequently there  is  noticed  soon  after  the  dropping  of  the  umbili- 
cal cord  a  small  reddish  excrescence  from  which  may  escape 
mucus,  occasionally  bile-stained,  and  in  some  cases  a  small 
amount  of  fecal  matter.  Not  infrequently  the  mucous  membrane 
of  the  duct  or  diverticulum,  and,  indeed,  in  some  cases  the  entire 
organ,  may  become  prolapsed  through  the  umbilicus,  forming  a 
tumor  (see  c,  Fig.  14)  which  is  known  as  a  mucous  polypus  or 
diverticulum  tumor.  The  tumor  is  usually  small,  about  the  size  of 
a  cherry  or  pea,  and  cylindric  in  shape  and  not  pedunculatcd.  It 
is  covered  with  mucous  membrane,  and  has  at  its  most  prominent 
part  a  small  opening  or  fistula.  By  means  of  a  probe  or  catheter 
this  opening  can  be  traced  to  the  intestine.  During  straining  at 
stool  or  paroxysms  of  coughing  the  entire  duct  may  prolapse 
through  the  umbilicus,  and  with  it  a  portion  of  the  proximal  in- 
testinal wall  (see  d,  Fig.  14)  or  a  small  complete  loop  of  intestine. 
(e,  Fig.  14.)  In  these  cases  the  tumor  is  larger,  often  the  size  of  a 
man's  fist,  irreducible,  is  sausage-shaped  and  often  bicornate. 
The  covering  of  the  tumor  is  the  mucous  membrane  of  the  in- 
testine. When  a  portion  of  the  intestinal  wall  prolapses,  there 
is  but  one  external  opening  or  fistula  which  bifurcates  a  short 
distance  from  the  surface,  one  portion  going  upward  and  the 
other  downward.  In  case  a  complete  section  of  the  intestine  has 
prolapsed,  two  openings  can  be  seen,  one  opening  passing  into  the 
upper  and  one  into  the  lower  segment  of  the  bowel. 

Prognosis. — When  the  tumor  is  composed  only  of  the  diver- 
ticulum and  not  accompanied  by  serious  prolapse,  the  prognosis 
is  good.  Prolapse  of  the  duct  alone  is  always  serious,  and  when 
accompanied  by  the  bowel,  the  result  is  usually  fatal  (Riesman). 
One  of  the  dangers  of  the  condition  arises  from  the  fact  that 
these  tumors  are  often  mistaken  for  other  growths,  and  operative 
procedures  are  attempted  which  are  followed  by  disaster. 
Strangulation  of  the  bowel,  caused  by  the  diverticulum  or  duct, 
may  also  occur. 

UMBILICAL  HERNIA. 

Hernia  through  the  umbilical  ring  arises  from  imperfect  closure 
of  the  parts.  The  congenital  form  may  be  the  result  of  the  non- 
closure  of  the  ventral  lamina,  or  it  may  be  due  to  the  continuance 
of  the  fetal  condition,  in  which  a  coil  of  intestines  remains  outside 
the  abdominal  cavity,  the  result  of  imperfect  closure  of  the  anterior 
walls  of  the  latter.  In  other  words,  there  is  an  arrest  of  devel- 
opment of  the  abdominal  walls,  while  one  or  more  coils  of  intes- 
tines, which,  during  embryonic  life  are  developed  outside  the 


UMBILICAL    HERNIA.  8/ 

abdominal  cavity,  fail,  by  the  deficient  development  of  the  latter, 
to  be  inclosed  in  the  usual  way.  Climate  seems  to  have  some 
effect  as  a  cause  of  umbilical  hernia  ;  thus,  according  to  Wert, 
Spain  and  Portugal  have  the  highest  percentage  of  cases  of 
hernia  in  proportion  to  the  population,  and  South  America  the 
lowest.  In  the  United  States,  Minnesota  has  the  highest  average 
and  West  Virginia  the  lowest.  Umbilical  hernia  may  be  con- 
genital or  acquired.  In  the  congenital  form  the  most  frequent 
cause  is  the  arrest  of  development  of  the  abdominal  walls,  as 
before  described.  Another  cause  of  this  variety  of  hernia  is 
probably  the  failure  of  the  normal  process  of  atrophy  of  the 
umbilical  vesicle.  The  acquired  form  is  much  more  generally 
seen  in  badly  nourished,  poorly  developed  children,  or  in  those 
who  have  been  weakened  or  debilitated  by  disease.  It  is  not 
infrequently  seen  in  children  with  chronic  diarrhea  or  in  the  same 
class  of  children  who,  from  any  reason,  have  violent  attacks  of 
vomiting  or  coughing.  An  elongated  uvula  may  act  as  a  sec- 
ondary cause  of  hernia  by  producing  violent  efforts  at  vomiting 
or  coughing.  Rectal  polypus  and  chronic  diarrhea  have  also 
been  given  as  causes.  No  matter  from  what  source  the  hernia 
arises,  it  will  appear  as  a  soft  tumor  in  the  center  of  the  umbilical 
ring.  This  tumor  will  be  increased  by  the  act  of  coughing  or 
efforts  of  bearing  down.  The  site  of  the  protrusion,  while 
usually  occurring  in  the  position  named,  occasionally  appears 
above  the  ring  between  the  recti  muscles.  In  this  latter  instance 
it  is  more  properly  called  ventral  hernia. 

Treatment. — In  early  life  a  complete  cure  can  often  be  effected 
by  drawing  the  two  sides  of  the  ring  together  after  replacing  the 
hernia,  and  passing  bands  of  rubber  adhesive  plaster  about  the 
abdomen  so  as  to  keep  the  ring  closed.  The  strips  should  be 
about  y?,  of  an  inch  wide.  This  dressing  must  be  repeated  from 
time  to  time  until  the  intestine  ceases  to  protrude.  Care  must 
be  taken,  however,  that  the  delicate  skin  is  not  chafed  by  the 
adhesive  plaster.  To  prevent  this  the  skin  may  be  dusted  with 
some  mild  aseptic  powder  before  dressing. 

The  ordinary  treatment  consists  of  covering  a  convex  button 
with  cotton  or  buckskin  and  making  pressure  against  the  ring 
with  the  convex  side  of  the  button,  the  latter  being  held  in  place 
by  a  bandage  around  the  abdomen. 

Operative  treatment  is  sometimes  useful.  When  the  umbilical 
ring  remains  open  and  surgical  means  can  not  be  tried,  the  hernia 
must  be  replaced  and  the  opening  closed  by  a  suitable  truss. 
This  truss  usually  consists  of  a  convex  rubber  button  held  in 
place  by  a  spring  or  a  rubber  bandage. 


CHAPTER  III. 

GENERAL    HYGIENE    OF    INFANTS    AND 
CHILDREN. 

As  soon  as  the  child  is  born  it  should  be  laid  on  its  side  upon 
the  bed,  far  enough  away  from  the  mother  to  prevent  her  rolling 
upon  it.  The  first  attention  after  severance  of  the  cord  should 
be  directed  to  the  breathing,  care  being  taken  that  inspiration  and 
expiration  are  regular.  Any  accumulation  of  mucus  in  the  mouth 
should  be  removed  by  a  finger  covered  with  soft  muslin  or  lint 
soaked  in  a  solution  of  boric  acid.  Should  the  respiration  be 
weak,  the  child  should  be  held  head  downward  and  a  small 
stream  of  cold  water  poured  on  the  chest.  Slapping  the  but- 
tocks or  chest  with  a  towel  wrung  out  in  cold  water  will  often 
aid  in  the  establishment  of  respiration.  When  asphyxiation 
occurs,  it  should  be  treated  according  to  methods  previously 
described.  Care  must  be  taken  to  see  that  no  bleeding  occurs 
from  the  umbilical  stump,  and  that  the  ligature  is  fastened  securely. 
The  material  used  for  the  ligature  must  be  sufficiently  strong  to 
hold  without  slipping,  and  at  the  same  time  not  be  so  thin  as 
to  cut  through  the  jelly  of  Wharton  or  possibly  the  umbilical 
vessels.  Frequently  if  slipping  of  a  ligature  does  occur  in  from 
twelve  to  twenty-four  hours  after  birth,  the  vessels  are  sufficiently 
contracted  to  prevent  hemorrhage ;  indeed,  we  have  observed  in 
at  least  two  cases  in  which  the  ligature  has  slipped  but  a  few 
hours  after  birth  that  the  hemorrhage  has  proved  very  slight. 
The  material  used  in  tying  the  cord  should  be  a  double  strand 
of  linen  thread  or  a  single  strand  of  "  G"  linen  fishing-line.  A 
stout  ligature  of  twisted  silk  will  do  very  well.  The  ligatures  in 
all  cases  must  be  rendered  aseptic  before  applying. 

The  eyes  of  the  new-born  infant  are  one  of  the  most  important 
objects  for  attention.  As  soon  as  respiration  is  established  and 
the  cord  tied,  the  eyes  should  be  carefully  washed  with  a  solution 
of  boric  acid  ;  in  many  cases  this  is  sufficient.  However,  it  is 
generally  recommended  that  a  drop  or  two  of  a  solution  of  five 
grains  of  nitrate  of  silver  to  the  ounce  of  distilled  water  be 
dropped  in  the  eyes  from  a  medicine  dropper.  This  may  again 
be  advantageously  followed  by  carefully  mopping  the  eyes  with 
sterilized  water  after  any  excess  of  silver  nitrate  has  been  neutral- 
ized by  instilling  a  few  drops  of  a  10  per  cent,  solution  of  sodium 


GENERAL    CARE    OF    THE    NEW-BORN    INFANT.  89 

chloric!.  When  the  mother  has  had  a  purulent  vaginal  discharge, 
it  is  often  necessary  to  instil  into  each  eye  a  few  drops  of  a 
i  :  12,000  solution  of  bichlorid  of  mercury,  followed  by  a  similar 
application  of  distilled  water.  Before  giving  the  infant  its  first 
bath  it  is  necessary,  on  account  of  the  sticky,  cheese-like  secre- 
tion which  covers  the  skin  (vernix  caseosa),  to  smear  the  child's 
body  with  either  olive  oil  or  vaselin.  Unless  this  is  done,  the 
vernix  caseosa  is  extremely  difficult  to  remove.  The  first  bath 
should  be  given  in  a  room  the  temperature  of  which  is  from  65° 
to  70°  F.  (18.3°  to  21.1°  C.) ;  the  temperature  of  the  water 
should  not  exceed  96°  F.  (35.6°  C.),  as  the  skin  of  the  new-born 
is  extremely  sensitive,  and  a  too  hot  bath  may  cause  irritation 
thereof,  which  may  amount  to  an  actual  dermatitis.  Soap  may 
be  used  in  this  bath,  providing  it  is  free  from  strong  alkalies,  the 
best  soap  being  a  superior  grade  of  Castile,  or,  as  some  recom- 
mend, Unna's  "overfatty  "  soap.  After  bathing,  the  skin  should 
be  mopped  dry  with  a  soft  towel,  after  which  it  should  be  dusted 
with  a  powder  consisting  of  2  per  cent,  of  salicylic  acid  and 
finely  powdered  starch,  or  boric  acid  or  thymol,  5  per  cent,  in 
starch  powder.  Some  prefer  to  use  the  oil  alone,  wiping  this 
carefully  off  after  applying,  and  to  use  no  water  for  several  days 
or  weeks. 

The  infant  should  be  dressed  in  a  soft,  unstarched  material, 
made  loose,  so  as  to  prevent  pressure  and  allow  perfect  freedom 
of  motion.  It  is  well  to  avoid  all  excessive  ornamentation  with 
lace.  The  diapers  should  be  made  of  soft  absorbent  material, 
and  a  sufficient  number  provided  to  allow  of  change  and  wash- 
ing after  each  evacuation  of  the  bowels  and  bladder. 

The  cord-stump  should  be  dusted  with  any  of  the  antiseptic 
powders  before  referred  to,  and  may  be  laid  so  that  the  severed 
portion  points  upward,  and  covered  with  a  little  bag  of  gauze  or 
a  small  pad  of  absorbent  cotton,  held  in  place  by  an  abdominal 
binder  of  light  flannel,  care  being  taken  that  this  bandage  is  loose 
enough  not  to  interfere  with  respiration. 

As  soon  as  the  child  is  washed  and  dressed  it  should  be  laid  in 
a  small  crib  by  itself.  It  should  never  be  allowed  to  sleep  in  the 
same  bed  with  the  mother,  as  there  is  danger  of  her  rolling  over 
on  it  during  sleep  and  causing  suffocation. 

Shortly  after  the  child  is  washed  and  dressed  it  should  receive 
a  teaspoonful  or  two  of  hot  sterilized  water  ;  this  acts  on  the  kid- 
neys, aiding  in  the  establishment  of  urination  and  stimulating 
renal  action  generally.  It  is  well  to  put  the  child  to  the  breast 
from  two  to  four  hours  after  birth,  or  as  soon  as  the  mother  is 
adequately  rested. 


QO  GENERAL    HYGIENE    OF    INFANTS    AND    CHILDREN. 

From  birth  to  the  end  of  the  sixth  or  eighth  month  the  infant 
should  sleep  from  n  P.M.  until  5  A.M.,  and  as  many  hours  dur- 
ing the  day  as  nature  demands  and  the  times  of  feeding,  washing, 
and  dressing  will  permit.  From  the  eighth  month  to  the  end  of 
two  and  a  half  years  the  child  should  sleep  from  noon  until  1.30 
or  2  P.M.,  and  at  the  time  of  taking  this  nap  it  is  to  be  undressed 
and  put  to  bed.  At  7  P.M.  it  should  be  put  to  bed  for  the  night. 
When  the  child  reaches  the  age  of  from  two  and  a  half  to  four 
years,  the  morning  nap  may  occasionally  be  omitted,  according 
to  indications,  but  in  all  cases  the  time  for  the  night's  rest  prop- 
erly begins  at  7.30  P.M.,  and  should  last  until  6  or  7  A.M. 
After  the  fourth  year  the  daytime  nap  need  not  be  insisted  upon, 
but  the  child  should  be  put  to  bed  by  8  P.M.,  and  sleep  for  at 
least  ten  hours.  When  possible,  the  sleeping-room  and  the  room 
occupied  in  the  day  ought  not  to  be  the  same ;  or;  when  this  is 
not  feasible,  the  child  should  be  removed  to  some  other  room  for 
an  hour  or  two  before  retiring  for  the  night  and  the  sleeping-room 
well  aired.  The  temperature  of  the  sleeping-room  should  be  from 
64°  to  68°  F.  (17.8°  to  20°  C),  and  this  temperature  is  to  be 
maintained  as  uniformly  as  possible. 

The  Bath. — The  child  should  be  bathed  at  a  regular  time  each 
day,  one  bath  in  the  twenty-four  hours  being  considered  enough. 
This  should  be  given  during  the  morning,  at  a  time  about  half- 
way between  the  first  two  feedings.  The  temperature  of  the  room 
should  then  be  about  96°  F.  (35.6°  C.),  and  kept  free  from 
drafts.  The  first  step  in  bathing  should  be  to  wet  the  child's 
head  thoroughly  in  order  to  prevent  its  taking  cold.  The  dura- 
tion of  the  bath  should  be  from  three  to  five  minutes,  after 
which  the  skin  must  be  well  dried  and  rubbed  with  a  moderately 
coarse  towel.  After  the  bath  the  body  should  be  covered  with 
a  blanket  or  flannel  night-robe,  and  the  infant  put  to  sleep  again 
for  a  short  time.  It  is  strongly  recommended  that  occasionally 
in  hot  weather  an  additional  sponge-bath  of  water  at  a  tempera- 
ture of  90°  F.  (32.2°  C.)  be  given,  which  will  have  a  cooling 
effect  upon  the  skin.  In  older  children  cool  baths  at  a  tempera- 
ture of  from  72°  to  76°  F.  (22.2°  to  24.4°  C.)  are  sometimes  more 
valuable  than  warm  ones.  Very  cold  baths,  except  in  rare  condi- 
tions, are  not  to  be  recommended  for  children.  They  are,  how- 
ever, occasionally  useful  as  a  tonic  or  stimulant,  increasing  the 
excretive  powers  of  the  skin  and  giving  tone  to  the  body.  These 
baths  must  always  be  given  in  a  warm  room,  the  child  standing  in 
enough  hot  water  to  cover  the  feet.  The  cold  water  should  be 
applied  by  means  of  a  sponge,  one  sponging  of  the  whole  body 
being  sufficient.  The  temperature  of  the  water  used  ought  not 


EXERCISE    AND    CARE    OF    THE    MOUTH.  91 

to  be  below  64°  F.  (17.8°  C).  In  many  cases  the  addition  of 
an  ounce  or  two  of  sea-salt  or  ordinary  rock-salt  will  increase 
the  good  effects  of  the  bath,  which  should  be  followed  by  a 
thorough  rubbing  with  the  hands  and  a  coarse  towel.  Another 
method  of  giving  a  cold  bath  is  to  allow  the  child  to  stand  in 
hot  water  while  the  body  is  enveloped  in  a  sheet  wrung  out  of 
water  at  a  temperature  of  60°  F.  (15.6°  C.),  and  the  entire  sur- 
face of  the  body  well  rubbed  through  the  sheet,  after  which  the 
child  is  rubbed  with  a  towel  until  the  skin  is  thoroughly  dry. 
This  method  is  applicable  to  older  children. 

A  bath  at  a  temperature  of  94°  to  100°  F.  (34.4°  to 
37.8°  C.)  is  frequently  used  to  produce  diaphoresis,  to  relieve 
nervous  irritability,  and  to  promote  sleep.  When  considerable 
stimulation  is  required,  mustard  may  be  added  to  the  water  in 
quantities  from  a  teaspoonful  to  a  tablespoonful.  As  a  general 
rule,  five  minutes  is  long  enough  for  immersion  in  a  hot  bath. 

Exercise. — Muscular  exercise  in  some  form  is  necessary  to 
the  maintenance  of  health.  Nature  provides  this  in  young 
infants  in  the  frequent  motion  of  the  whole  body,  so  that  all 
that  is  necessary  is  to  undress  a  young  baby  and  let  it  lie  on  its 
back  and  kick  and  move  at  will.  As  the  child  begins  to  creep, 
and  later  to  walk,  the  muscles  of  locomotion  and  of  coordinated 
action  are  slowly  developed. 

A  baby  may  be  taken  out-of-doors  in  from  three  weeks  to  a 
month  after  birth,  and  from  that  time  on  it  should  be  kept  in  the 
open  air  for  a  certain  part  of  every  day,  providing  the  weather  per- 
mits. Moderately  cold  weather,  if  the  air  is  dry  and  there  is  no 
wind,  need  not  keep  any  but  a  very  young  infant  indoors  ;  the 
child,  however,  should  be  well  wrapped  up.  In  hot  weather  the 
head  should  be  protected,  and  the  child  should,  of  course,  be  kept 
away  from  the  direct  rays  of  the  sun.  Exercise  in  older  children 
is  best  managed  in  the  moderate  use  of  the  ordinary  games, 
especially  those  which  take  the  child  out-of-doors.  Games  not 
only  help  to  develop  the  muscular  system,  but  also  give  the 
child  an  object  to  obtain  in  mastering  them  ;  besides  this,  the 
obedience  taught  by  the  rules  .of  games  affords  a  certain  disci- 
pline which  acts  for  their  good.  In  stormy  weather  children 
may  be  warmly  clad  and  allowed  to  run  about  and  play  in  a  room 
with  the  windows  open.  As  a  rule,  it  is  best  not  to  allow  a  child 
out-of-doors  at  night. 

Care  of  the  Mouth. — The  mouth  of  the  newly  born  infant 
should  'be  gently  cleansed  every  day  with  boiled  water  and  a 
soft  cloth.  The  hands  of  the  mother  or  nurse  should  be  clean 
before  attempting  to  wash  the  mouth  of  the  infant.  Too  frequent 


92  GENERAL    HYGIENE    OF    INFANTS    AND    CHILDREN. 

or  any  but  the  most  gentle  methods  of  doing  this  are  to  be  dis- 
couraged, as  the  epithelium  of  the  mouth  of  the  infant  is  very 
delicate  and  much  harm  may  be  done  by  injuring  it.  From  the 
appearance  of  the  first  tooth  on  through  to  the  cutting  of  both 
temporary  and  permanent  sets,  the  teeth  should  be  carefully  and 
gently  brushed  once  or  twice  a  day.  Neglect  of  this  predis- 
poses the  teeth  to  become  carious,  and  should  this  occur,  the 
child  should  be  referred  to  a  good  dentist  and  have  the  carious 
teeth  filled  or  extracted.  Carious  teeth  are  not  only  unsightly, 
but  they  give  rise  to  bad  breath,  pain,  and  frequently  form  the 
starting-point  for  infection. 

Care  of  the  Genital  Organs. — The  genital  organs  of  chil- 
dren should  receive  attention,  particularly  as  to  cleanliness.  In 
the  male  child  if  the  foreskin  is  long  and  the  preputial  orifice  of 
normal  size,  simply  drawing  back  the  former  and  carefully,  but 
thoroughly,  cleansing  the  glans  with  warm  borax  water  or  with 
Castile  soap  and  water  is  enough.  When  the  preputial  orifice  is 
somewhat  contracted  and  adherent,  the  adhesions  should  be 
broken  up  by  gently  rotating  the  closed  blades  of  a  small  pair 
of  dressing  forceps  about  the  glans,  after  which  the  prepuce 
should  be  stretched  gradually  from  day  to  day  until  the  foreskin 
can  be  drawn  easily  back  over  the  glans.  When  the  foreskin  is 
very  long,  circumcision  should  be  done. 

The  genital  organs  of  female  children  require  little  but  simple 
cleanliness. 

The  Nursery. — The  nursery  must  be  a  fairly  large  room, 
preferably  facing  the  south,  so  that  plenty  of  sunlight  can  enter 
it  freely.  If  possible,  it  should  not  be  on  the  ground  floor  or, 
on  the  other  hand,  it  should  not  be  at  the  top  of  so  many  flights 
of  stairs  as  to  be  inconvenient.  It  should  be  heated  by  an  open 
fire  or,  as  Holt  recommends,  by  a  Franklin  radiator.  Steam 
heat  or  gas  should  not  be  used.  Ventilation  is  of  the  greatest 
importance,  and  at  the  same  time  direct  drafts  are  to  be  avoided  ; 
this  can  be  accomplished  best  by  any  of  the  usual  forms  of  ven- 
tilators which  are  designed  to  be  placed  in  the  windows.  The 
furniture  should  be  simple  in  style,  not  too  much  in  quantity, 
and  of  plain,  solid  surface,  not  basket  woven,  so  that  it  can  be 
easily  cleaned.  All  heavy  hangings  are  to  be  condemned.  The 
floors  should  be  covered  with  rugs,  tightly  fastened  to  prevent 
the  child  or  nurse  with  the  baby  in  her  arms  from  tripping. 
The  bed  on  which  the  child  lies  should  be  furnished  with  a  hair 
mattress  and  a  pillow  of  the  same  material  ;  no  hangings  of  any 
sort  should  be  used  about  the  bed.  Cradles  that  rock  are  an 
abomination,  and  should  be  excluded.  For  lighting  a  nursery 


THE    NURSERY.  93 

oil  or  gas  may  be  used  ;  the  former  presents  many  points  of 
usefulness  providing  the  lamps  can  be  so  placed  that  they  can 
not  be  upset ;  on  the  whole,  gas  is  to  be  preferred.  At  night  a 
small  wax  night-light  is  all  that  is  required.  The  temperature 
of  the  room  should  not  be  above  70°  F.  (21.1°  C.)  during  the 
day  and  about  64°  F.  (7.8°  C.)  at  night.  The  nursery  should 
not  be  used  as  a  place  for  drying  diapers  and  clothes  generally  ; 
nothing  can  be  more  unhealthy,  not  to  say  disgusting,  than  to 
see  a  line  filled  with  diapers  hanging  in  front  of  a  nursery  fire — 
a  sight  much  too  familiar  to  many  physicians. 


CHAPTER   IV. 

FEEDING  AND  FOOD  OF  INFANTS  AND 
CHILDREN. 

Probably  the  most  important  factors  in  the  care  of  infants  and 
young  children  are  the  selection  and  preparation  of  their  food  and 
the  manner  and  regularity  in  which  it  is  given.  Nature  has  pro- 
vided in  the  milk  of  the  healthy  human  female  a  food  perfectly 
adapted  to  the  needs  of  the  infant.  When  the  secretion  of  milk 
is  plentiful  and  of  good  quality,  the  question  of  the  nourishment 
of  the  child  is  a  very  simple  one.  It  is  only  when  various  dis- 
turbing causes  affect  the  mother's  milk  and  artificial  foods  must 
be  resorted  to  that  the  regulation  of  the  one  and  the  selection  of 
the  other  are  matters  which  require  much  thought  and  consider- 
able scientific  knowledge.  The  infant  may  be  fed  in  one  of  four 
ways  :  from  the  mother's  breast,  from  the  breast  of  a  wet-nurse, 
by  the  milk  of  animals  so  modified  as  to  resemble  human  milk, 
and  by  foods  containing  starch  or  maltose.  It  is  a  mistake  to 
suppose  that  in  all  cases  the  mother's  milk  is  the  best  food  for 
the  child.  It  is  only  when  it  is  of  such  quality  and  quantity  as 
to  be  thoroughly  adapted  to  the  digestive  organs  of  the  infant 
that  it  fulfils  all  that  is  required  of  it.  In  order  to  supply  a  good 
quality  of  milk  the  mother  should  be  strong  and  healthy,  pro- 
vided with  proper  food,  and  be  maintained  in  good  hygienic  sur- 
roundings. She  should  have  a  reasonably  even  temperament 
and  be  desirous  and  willing  to  take  upon  herself  the  various  re- 
sponsibilities of  her  position  and  to  make  it  her  special  mission 
to  fit  herself  for  the  duties  of  nurse.  During  the  period  of  lac- 
tation all  other  responsibilities  must  give  way  to  those  of  the  care 
and  feeding  of  her  child. 

FEEDING  FROM  THE  BREAST. 

The  Breast. — The  breast  is  a  compound  racemose  gland,  whose 
glandular  tissue  is  lined  with  a  peculiar  type  of  epithelium  en- 
dowed with  the  power  of  extracting  from  the  blood  the  peculiar 
properties  of  fat,  proteids,  and  sugar  which,  held  in  suspension  in 
water  and  combined  with  salts,  form  that  peculiar  emulsion  which 

94 


FEEDING  FROM  THE  BREAST.  95 

we  call  milk.  The  secretion  of  milk,  and,  indeed,  the  formation 
of  its  various  component  parts,  may  be  influenced  by  many 
causes.  It  has  been  many  times  proved  that  the  various  emo- 
tions, changes  of  atmosphere  and  food,  overexertion,  mental  de- 
pression or  shock,  and  many  other  causes  will  change  the  com- 
position and  qualities  of  milk  so  as  to  render  it  indigestible. 
Even  variations  in  the  regularity  of  the  intervals  between  nurs- 
ings may  produce  an  effect  upon  the  milk  ;  thus,  as  Rotch  has 
pointed  out,  a  prolonged  interval  lessens  the  solid  constituents  in 
their  proportion  to  the  water,  while  a  too  short  interval  increases 
the  amount  of  solids  in  proportion  to  the  water  in  the  milk.  It 
is  also  possible  that  the  appearance  and,  to  a  greater  extent,  the 
continuance  of  menstruation  influence  the  quality  of  milk,  and 
pregnancy  certainly  does  so  to  a  very  marked  degree. 

An  infant  should  be  put  to  the  breast  within  from  two  to  four 
hours  after  birth,  or  as  soon  as  the  mother  is  thoroughly  rested 
from  her  labor.  At  this  time,  except  in  rare  instances,  very  little 
milk  is  secreted,  and  the  infant  will  get  practically  nothing  but 
colostrum,  which  has  a  slightly  laxative  effect.  It  will  often  be 
found  that  at  first,  and  at  several  subsequent  attempts  at  nursing, 
the  infant  fails  to  take  hold  of  the  nipple,  and  some  method  must 
be  adopted  to  teach  the  child  how  to  nurse.  This  can  be  best 
done  by  drawing  the  nipple  out  carefully  and  moistening  it  with 
a  little  sugar  and  water  or  barley-water  or,  better,  by  squeezing 
gently  a  drop  of  milk  from  the  nipple.  This  must  be  done 
before  each  nursing  until  the  child  learns  how  to  take  the  nipple 
itself.  It  is  of  great  importance  that  the  child  shall  early  be 
accustomed  to  regular  hours  of  feeding  during  the  first  week  of 
life  or  until  the  milk  secretion  is  thoroughly  established.  The 
infant  should  be  put  to  the  breast  every  two  hours  during  the 
day,  and  if  asleep,  should  be  awakened  and  encouraged  to  nurse, 
rather  than  allowed  to  get  into  the  habit  of  nursing  at  irregular 
intervals.  This  is  of  importance  not  only  for  the  child,  but  also 
for  the  proper  maintenance  of  the  quality  of  the  mother's  milk. 
At  night,  however,  it  is  well  both  for  the  sake  of  the  mother  and 
child  that  the  nursing  should  not  be  attempted  at  so  frequent 
intervals  as  during  the  day.  The  digestive  organs  of  the  young 
infant  need  the  night  in  which  to  rest,  just  as  do  those  of  the  adult, 
and  it  is  only  fair  that  the  mother  should  also  enjoy  this  time 
for  rest  and  repose.  However,  as  the  interval,  say  from  10  P.M., 
the  time  of  the  child's  last  nursing,  until  early  in  the  morning,  is 
rather  too  long  for  a  young  infant  to  go  without  some  nourish- 
ment, it  is  well  that  it  should  be  put  to  the  breast  once  during 
this  time.  The  following  table  gives  the  number  of  feedings  for 


96 


FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 


the  day  and  night  and  the  intervals  between  each  from  birth  to 
the  end  of  the  first  year  : 


AGE. 

INTERVALS. 

NUMBKR  OF  FEED- 
INGS IN  TWENTY- 
FOUR  HOURS. 

NUMBER  OK  NIGHT 
FEEDINGS. 

From  birth  to  4  weeks,  . 

2  hours. 

10 

I 

From  4  to  6  weeks,    .    . 

2        ' 

9 

I 

From  6  to  8  weeks,    .    . 

2^  ' 

8 

I 

From  2  to  4  months,  .    . 

2#« 

7 

o 

From  4  to  10  months, 

3      ' 

6 

0 

From  10  to  12  months,  . 

3      ' 

5 

o 

The  length  of  time  during  which  the  child  should  be  allowed 
to  nurse  at  each  feeding  must  vary  a  little  according  to  the 
amount  of  milk  secreted,  its  quality,  and  the  general  condition 
of  the  child.  The  fairly  strong  infant  a  week  old  will  be  able  to 
retain  in  its  stomach  from  one  to  three  ounces  of  milk,  and  to 
get  this  will  require  that  the  child  be  kept  at  the  breast,  on  an 
average,  for  about  fifteen  minutes.  After  the  third  day  or  on  the 
beginning  of  the  fourth  the  secretion  of  the  milk  is  w.ell  estab- 
lished. The  filling  of  the  breasts  is  sometimes  accompanied  by 
a  slight  rise  of  temperature  and  some  nervous  disturbance.  The 
breasts  at  this  time  become  swollen,  tense,  and  more  or  less 
painful.  After  the  secretion  of  milk  is  thoroughly  established 
the  child  must  be  put  to  the  breast  at  regular  intervals  ;  this  is 
of  the  utmost  importance  not  only  to  the  infant,  but  also  to  the 
mother,  as  regularity  in  nursing  helps  the  breasts  to  produce  a 
milk  of  even  quality  and  quantity.  It  is  of  importance  that  the 
mother,  especially  if  the  child  be  her  first,  be  taught  how  to 
nurse  it,  and  also  how  to  regulate  her  own  life,  diet,  exercise, 
etc.,  so  as  to  keep  the  nutritive  properties  of  her  milk  in  the  best 
possible  condition.  This  knowledge  does  not  come  by  instinct 
in  the  majority  of  cases,  as  many  seem  to  believe,  but  must  fre- 
quently be  taught  by  the  physician. 

While  feeding  from  the  breast,  the  infant  should  be  held  partly 
on  the  side,  and  may  suck  from  the  right  or  left  breast,  the 
better  plan  being  to  nurse  it  from  each  breast  alternately.  The 
mother  should  sit  in  a  comfortable  position,  on  a  rather  low 
chair,  with  the  body  bent  slightly  forward  and  the  nipple  drawn 
out  so  that  the  child  can  easily  take  hold  of  it.  One  of  the 
mother's  hands  may  be  used  to  regulate  the  flow  of  the  milk  by 
placing  the  first  and  second  fingers  above  and  below  the  nipple. 
It  is  of  the  greatest  importance  that  when  nursing  the  child  the 
mother  should  not  be  overheated,  or  have  recently  suffered  from 


f  OSTf  OP 

FEEDING    FROM    THE    BREAST.  97 

any  profound  nervous  disturbance.  After  the  child  has  been  sat- 
isfied, the  nipple  should  be  washed  with  a  mild  solution  of  boric 
acid,  and  in  many  instances  it  is  well  that  the  child's  mouth 
should  be  treated  in  the  same  manner.  In  cases  where  fissures 
or  erosions  of  the  nipple  occur  and  nursing  is  extremely  pain- 
ful, a  nipple-shield  may  be  used.  Of  these,  many  styles  are  on 
the  market ;  probably  the  best  is  made  of  a  simple  bell  of  glass 
to  which  is  attached  a  rubber  nipple.  Care  should  be  taken 
that  these  nipple-shields  be  kept  scrupulously  clean,  or  they  may 
cause  infection  of  the  breast.  Although  intervals  of  about  three 
hours  between  each  feeding  may  be  well  followed  in  the  majority 
of  cases,  still  no  fixed  rule  can  always  be  maintained,  as  all 
women  do  not  secrete  the  same  quantity  and  quality  of  milk,  and 
one  infant  may  not  take  the  same  amount  in  a  given  time  as  an- 
other ;  but  it  is  of  the  utmost  importance  that  whatever  interval 
be  first  adopted,  this  shall  be  maintained,  unless  there  is  some 
exceedingly  good  reason  for  changing  it.  When  the  secretion 
of  milk  is  plentiful,  the  child  should  be  kept  on  breast  milk  alone 
until  about  the  eighth  or  ninth  month,  when  the  child  should  be 
gradually  weaned.  The  best  method  of  doing  this  is  gradually 
to  substitute  modified  milk  for  breast  feeding  at  the  rate  of  one 
artificial  meal  every  second  twenty-four  hours.  At  first  no  two 
artificial  feedings  should  follow  immediately  after  each  other. 
At  the  commencement  of  the  artificial  feeding  a  formula  should 
be  used  which  contains  slightly  less  proteids  than  the  mother's 
milk,  and  this  element  should  be  gradually  increased,  providing 
the  infant's  digestion  bears  it  well,  until  whole  cow's  milk  is 
taken.  This  will  be  at  about  the  tenth  or  eleventh  month.  As 
the  child  grows  older  one  of  the  proprietary  foods  containing 
maltose  or  starch,  which  can  be  given  mixed  with  milk,  may 
be  used  as  a  food.  A  small  amount  of  animal  food  in  the  form 
of  broths  or  finely  chopped  tenderloin  should  be  given  once  a 
day. 

Contraindications  to  Breast  Feeding. — Women  who  are 
affected  with  acute  fevers,  syphilis,  tuberculosis,  or  any  form  of 
wasting  disease  should  not,  as  a  rule,  nurse  their  children. 
Women  who  have  uncontrollable  attacks  of  temper  or  who 
are  subject  to  violent  emotions  do  not,  as  a  rule,  make  good 
nursing  mothers.  Unwillingness  to  nurse  the  infant,  irregulari- 
ties in  rest  and  exercise,  continued  indiscretions  in  diet,  are  all 
classed  as  contraindications  to  nursing. 

Diet  and  Hygiene  of  Lactation. — It  is  of  the  greatest  impor- 
tance that  the  nursing  mother  be  given  a  diet  of  good  wholesome 
food  containing  all  the  elements  necessary  to  keep  her  general 
7 


98  FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 

health  in  the  best  possible  condition.  Food  undoubtedly  exer- 
cises a  potent  influence  over  the  formation  of  milk.  During  the 
lying-in  period  the  diet  should  be  light  and  at  the  same  time  of 
sufficient  quantity.  It  should  consist  of  milk,  soup,  vegetables, 
bread  and  butter,  and  gruels.  After  the  first  week,  meat  in 
moderate  quantities  should  be  given.  Weak  tea  and  coffee  may 
be  allowed  in  small  quantities,  and  cocoa  and  chocolate  are  both 
nutritious  and  pleasant.  The  malt  liquors  have  been  used  for 
the  purpose  of  stimulating  the  secretion  of  the  milk,  but  it  is 
questionable  whether  they  are  of  much  value  for  this  purpose. 
Fish  may  be  used  sparingly,  since  in  some  instances  it  possibly 
may  have  a  certain  deleterious  effect  upon  the  milk.  Exercise 
in  the  open  air  is  of  great  importance  in  maintaining  the  equi- 
librium of  milk  secretion  ;  the  amount,  however,  must  be  arranged 
to  suit  the  strength  of  the  individual  and  should  be  regularly 
practised. 

Deficiency  in  the  Secretion  of  Milk. — When  the  secretion 
of  milk  is  poor,  we  should  first  attempt  to  stimulate  it  before 
taking  the  child  from  the  breast  and  depending  for  its  nourish- 
ment upon  the  use  of  any  of  the  much  inferior  modifications  of 
cow's  milk  or  the  still  worse  artificial  foods.  The  secretion 
of  milk  can  be  stimulated  by  increasing  the  amount  of  milk- 
producing  foods  which  the  mother  should  take.  The  best  of  these, 
probably,  is  the  extract  of  meats  in  the  form  of  broths  or  soups. 
It  has  been  many  times  proved  that  a  diet  largely  of  proteids 
will  increase  the  quantity  of  all  the  elements  in  the  milk.  Rotch 
has  also  pointed  out  that  a  diet  consisting  largely  of  fats  will  not 
increase  that  element,  but  rather  decrease  it  in  milk.  Next  in 
efficiency  are  milk,  cocoa,  and  chocolate  taken  at  meals  once  or 
twice  a  day.  As  has  been  before  stated,  some  of  the  malt  liquors, 
particularly  beer  and  porter,  are  sometimes  used  to  stimulate  the 
secretion  of  milk,  but  the  prejudice  against  them  and  the  danger 
of  forming  the  alcohol  habit  should  make  us  extremely  careful 
as  to  whom  we  recommend  their  use.  Certain  drugs,  also,  are 
of  service  for  this  purpose  ;  foremost  among  these  we  have 
castor  oil,  given  in  small  doses — say  from  ten  to  fifteen  drops  in 
a  soft  capsule  and  repeated  four  or  five  times  a  day.  Pilocarpin, 
given  in  the  ordinary  medicinal  doses,  may  be  of  some  value  in 
increasing  the  quantity  of  milk.  Massage  of  the  breasts  per- 
formed once  or  twice  a  day  is  a  useful  adjunct  for  this  purpose. 

Regulation  of  diet,  exercise,  and  general  mode  of  life  do 
much  to  improve  the  quantity  and  quality  of  milk  in  a  woman 
whose  secretion  is  deficient.  When  the  watery  elements  are 
deficient  in  quantity,  these  can  often  be  corrected  by  allowing 


FEEDING    FROM    THE    BREAST. 


99 


the  woman  to  drink  a  larger  amount  of  liquids.  Too  large  a 
proportion  of  water  can  be  reduced  by  decreasing  the  amount  of 
fluids  taken  or  by  the  administration  of  saline  cathartics.  The 
latter  method  should  be  used  with  caution  as  it  sometimes  pro- 
duces colic  and  diarrhea  in  the  child. 


TABLES  SHOWING  TYPICAL  ANALYSES  OF  A  NORMAL,  A  POOR, 
AN  OVERRICH,  AND  A  BAD  HUMAN  BREAST  MILK.— (Hatch.) 


NORMAL  MILK. 
Healthy  life  as  to 
exercise  and  food. 

POOR  MILK. 
Starvation. 

OVERRICH  MILK. 
Rich  feeding  ;  lack 
of  exercise. 

BAD  MILK. 
Pregnancy, 
disease,  etc. 

Fat,        

4.OO 

I    IO 

c  10 

o  80 

Sutrar. 

7  OO 

A    OO 

7  SO 

e  00 

Proteids,    .... 
Ash,       

I.SO 
O.  IS 

2.50 

O.OQ 

3-50 
o.  20 

4-5° 
o  oo 

Total  solids, 
Water,       .... 

12.65 

87.35 

7.69 
92.31 

16.30 

83.70 

10.39 

89.61 

Total,     .    .    . 

IOO.OO 

IOO.CO 

IOO.OO 

100.00 

SHOWING  THE  EFFECTS  OF  MENSTRUATION  ON  HUMAN  MILK. 


NORMAL. 

SECOND  DAY 
OF  MENSTRUA- 
TION. 

SEVEN  DAYS 
AFTER  MENSTRU- 
ATION. 

FORTY  DAYS 
AFTER  MEN- 
STRUATION. 

Fat,    

4..OO 

1.  37 

2.  02 

2.74 

7.00 

6.  10 

6.55 

6.35 

Proteids,    .... 
Ash,       .... 

1.50 

O.  IS 

2.78 
O.IS 

2.12 
O.IS 

0.98 
0.14 

Total  solids, 
Water,       .... 

12.65 
$7-35 

10.40 
89.60 

10.84 
89.16 

IO.2I 

89.79 

Total,     .    .    . 

IOO.OO 

IOO.OO 

100.00 

100.00 

When  the  total  quantity  of  milk  is  too  great,  the  amount  of 
liquids  should  be  decreased  and  the  total  quantity  of  food  some- 
what limited  in  amount.  When  the  total  amount  of  solids  is 
too  small,  the  nursing  intervals  should  be  shortened,  the 
amount  of  liquids  decreased,  and  less  exercise  should  be 
recommended.  When  the  total  amount  of  solids  is  too  large, 
the  nursing  interval  should  be  prolonged,  the  amount  of 
exercise  should  be  increased,  as  should  also  the  proportion 
of  liquids  in  the  mother's  diet.  When  the  fat  is  deficient  in 
quantity,  the  proportion  of  meat  in  the  diet  should  be  increased. 
The  reverse  of  this  is  indicated  when  the  amount  of  fat  is  too 


IOO     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

great.  When  the  percentage  of  proteids  is  too  low,  the  exercise 
should  be  decreased,  the  amount  of  proteid  diet  increased,  and 
when  the  amount  of  proteids  is  too  high,  the  amount  of  exercise 
should  be  increased  up  to  the  limits  of  fatigue,  and  the  proteids 
in  the  diet  decreased  in  quantity. 

In  cases  in  which  there  is  an  oversecretion  of  milk  and  the 
breasts  become  pendulous,  it  is  of  great  use  to  support  them  by 
means  of  a  firm  binder  made  of  one  or  two  thicknesses  of  muslin 
passed  around  them  and  pinned  from  below  upward.  This 
binder  should  be  removed  at  the  time  of  nursing. 

Disturbances  of  Lactation. — The  chief  causes  of  the  various 
disturbances  of  lactation  are  menstruation  and  pregnancy ;  the 
former  may  or  may  not  produce  change  of  sufficient  conse- 
quence to  warrant  the  weaning  of  the  'child.  Not  infrequent^ 
by  pumping  the  breasts  during  the  time  of  the  menstrual  epoch, 
it  is  possible  to  tide  both  mother  and  child  over  these  periods, 
and  nursing  may  be  continued  afterward.  As  a  rule,  however, 
the  continuance  of  menstruation  affects  the  composition  of  the 
milk  to  quite  a  marked  degree.  Pregnancy,  as  a  rule,  creates  a 
much  greater  disturbance  in  the  equilibrium  of  milk  secretion 
than  does  menstruation,  so  much  so  that  as  a  general  rule  it  is 
probably  best  to  wean  the  child  as  soon  as  it  is  known  that  the 
mother  is  pregnant.  The  table  on  page  99  will  show  the  varia- 
tions in  milk  due  to  menstruation,  pregnancy,  and  marked 
abnormalities  in  nutrition. 

WEANING. 

The  age  at  which  the  child  should  be  weaned  can  not  be 
definitely  fixed,  as  it  varies  somewhat  with  the  amount  and.  rich- 
ness of  the  milk  secreted  by  the  mother  and  the  general  condi- 
tion of  the  child.  In  the  majority  of  cases  it  is  not  considered 
desirable  to  continue  breast  feeding  beyond  the  eleventh  or 
twelfth  month.  If  it  is  at  all  possible,  a  child  should  not  be 
weaned  before  the  starch-digesting  (amylolytic)  function  of  the 
digestive  apparatus  is  well  developed.  This  does  not  occur 
before  the  sixth  or  eighth  month,  or,  in  other  words,  about  the 
time  the  first  four  incisor  teeth  are  cut.  Let  us  say,  then,  that 
a  child  may  be  weaned  at  about  the  ninth  month.  After  the 
twelfth  month  the  child  needs  a  stronger  food  than  the  mother's 
milk  affords,  and  continued  lactation,  heretofore  a  purely  physio- 
logic function,  begins  to  cause  a  considerable  drain  on  the 
vitality  of  the  mother.  Many  authorities  believe,  and,  indeed,  in 
a  number  of  cases  facts  seem  to  prove,  that  from  this  time  the 


WEANING. 


101 


milk  slowly  becomes  poorer  in  quality,  and  this  is  particularly 
apt  to  be  the  case  if  menstruation  or  pregnancy  appear  and 
continue.  It  is  best  that  a  child  should  not  be  weaned  during 
the  intense  heat  of  midsummer,  because  of  the  danger  of  gastro- 
intestinal infection  from  cow's  milk  or  other  methods  of  artificial 
feeding.  If  possible,  it  is  preferable  to  wean  an  infant  during 
one  of  the  interdental  periods  and  in  the  cooler  months  of  the 
year.  The  infant  may  be  weaned  either  suddenly  or  by  the 
gradual  substitution  of  an  artificial  diet.  The  former  method  is 
only  indicated  when  there  is  a  continued  and  persistent  refusal  on 
the  part  of  the  child  to  take  the  breast,  or  when  the  milk  becomes 
suddenly  changed  from  any  cause,  so  as  to  have  a  bad  effect 
upon  the  infant's  health.  Should  the  mother  become  affected 
with  any  disease,  such  as  erysipelas,  cancer,  tuberculosis,  or  the 
acute  fevers,  we  must  regard  this  as  an  indication  for  the  rapid 
withdrawal  of  breast  feeding.  An  infant  may  be  gradually 
weaned  by  mixed  feeding  in  the  following  manner :  If  the  child 
be  put  to  the  breast  every  three  hours,  there  should,  during  the 
first  week,  be  one  artificial  feeding  introduced  daily.  During 
the  second  week  two  artificial  feedings  and  five  breast  feedings 
may  be  given,  and  in  this  manner  increasing  the  number  of 
artificial  feedings  by  one  and  reducing  the  number  of  nursings 
in  the  same  proportion  until  the  child  is  fed  entirely  on  an  arti- 
ficial diet. 


METHOD  OF  GRADUAL  WEANING.— (Cant/ey.) 


FIRST 
WEEK. 

SECOND 
WEEK. 

THIRD 
WEEK. 

FOURTH 

WEEK. 

FIFTH 
WEEK. 

5    A.  M  

Breast. 

Breast 

Breast 

Breast 

Breast 

8   A.  M  

Mixture. 

Mixture 

Mixture 

Mixture 

1  1    A.  M  

Breast. 

Breast. 

Breast. 

Mixture. 

Mixture. 

2  r.  M  

Breast. 

Breast. 

Mixture. 

Mixture. 

Mixture. 

5    P.  M. 

Breast. 

Breast. 

Breast. 

Breast. 

Mixture. 

8    P.  M  

Breast. 

Mixture. 

Mixture. 

Mixture 

Mixture 

1  1    P.  M  

Breast. 

Breast. 

Breast. 

Mixture 

Mixture. 

It  is  of  importance  to  know,  and  it  sometimes  requires  no  little 
study  and  care  to  find  out,  what  food  shall  be  used  to  replace 
the  mother's  milk  in  these  cases. 

At  the  present  time  the  opinion  of  the  majority  of  those  who 
have  carefully  studied  infant  feeding  seems  to  be  in  favor  of  sub- 
stituting suitably  modified  cow's  milk  for  that  of  the  mother 
when  the  child  must  be  weaned.  If  the  mother  is  healthy  and 


IO2     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

her  milk  agrees  with  her  baby  and  the  latter  is  increasing  in 
weight,  the  substituted  food  must  be  made  to  correspond  in 
the  proportion  of  its  elements  as  nearly  as  possible  to  her  milk, 
an  analysis  of  which  should  be  made.  When  the  weaning  is 
necessary  before  the  ninth  month,  such  an  analysis  is  particu- 
larly required.  In  case  the  mother's  milk  has  not  agreed  with 
the  child  and  weaning  has  been  imperative  on  that  account,  an 
analysis  will  show  which  milk  element  is  at  fault,  and  this  must  be 
corrected  in  the  milk  mixture  ;  it  must  always  be  remembered 
that  the  proteids  of  cow's  milk  are  more  indigestible  than  those 
of  the  mother  ;  therefore  it  is  well  to  start  with  a  mixture  con- 
taining a  somewhat  lower  proportion  of  proteids  than  the  mother's 
milk  contains. 

From  the  beginning  of  artificial  feeding  the  child  should  be 
weighed  at  regular  intervals,  and  its  digestion,  bowel  move- 
ments, and  general  condition  carefully  watched.  If  the  infant 
loses  weight,  the  food  is  insufficient  in  some  way,  and,  as 
will  be  shown  later,  the  milk  element  which  is  at  fault  will 
very  often  show  in  the  character  of  the  stools  or  general  symp- 
toms. 

After  the  child  has  been  entirely  weaned  and  is  on  a'  diet  com- 
posed exclusively  of  modified  milk,  a  mixture  having  been  made 
which  is  agreeing,  it  should  be  our  aim  to  raise,  first,  the  total 
quantity  as  the  infant's  gastric  capacity  increases,  then  the  pro- 
portion of  proteids  should  be  increased,  and,  as  the  child  grows 
older,  the  quantity  of  fat  diminished.  If  the  child  has  been 
weaned  at  the  end  of  the  usual  period  of  lactation,  say  ten  or 
eleven  months,  and  the  mother's  milk  has  agreed  up  to  that  time, 
the  child  should  be  gradually  weaned,  and  at  first  fed  with  a 
milk  mixture  corresponding  with  the  proportions  of  the  mother's 
milk.  As  soon  as  a  formula  has  been  made  which  agrees,  the 
proteids  should  be  rapidly  increased,  the  ultimate  object  being  to 
train  the  digestive  organs  to  assimilate  unmodified  cow's  milk. 
This  will  be  about  at  from  the  twelfth  to  the  fourteenth  month. 
In  the  practice  of  many  physicians,  especially  those  residing  in 
the  country,  it  is  a  hard  matter  to  have  milk  analyses  made,  and 
some  simpler  method  must  be  used. 

It  is  difficult,  in  fact  impossible,  to  make  a  milk  formula  which 
will  fit  all  cases,  but,  as  a  rule,  in  starting  a  child  on  a  milk  mix- 
ture it  is  best,  for  the  first  few  days,  to  give  a  formula  low  in 
proteids  and  rather  rich  in  fats  and  sugar  if  the  child  is  between 
three  and  six  months  of  age.  As  a  first  formula  for  a  child 
three  months  old  the  authors  have  had  good  results  from  a  mix- 
ture of: 


WEANING.  1O3 

Fat, 4.00 

Sugar, 6.00 

Proteids, l.oo 

Lime-water, 5.00 

This  can  be  made  as  follows  : 

Cream  containing  1 6  per  cent,  fat, I       ounce 

Boiled  water, 22j^  drams 

Lime-water,      \yz       " 

Milk-sugar, y2  dram. 

This  is,  however,  an  arbitrary  formula,  based  on  personal 
experience  only.  We  have  also  found  the  following,  devised  by 
Rotch,  most  useful  as  a  basic  formula  for  a  child  two  or  three 
months  old  which  must  be  fed  artificially.  This  consists  of: 

Fat, 2.00 

Sugar, 5.00 

Proteids, 0.75 

Lime-water,      5.00 

And  is  made  as  follows  : 

Cream, 4  ounces 

Milk, none 

Lime-water, I  ounce 

Water, 15  ounces 

Milk-sugar, 7  drams, 

Or  half  the  quantity  of  granulated  sugar.     The  cream  used  con- 
tains 10  per  cent,  of  fat. 

In  these  milk  formulas  our  idea  is  simply  to  describe  a  type 
of  milk  mixture.  In  every  case  the  milk  elements  must  be 
changed  to  suit  the  digestion  of  the  particular  child.  The  aver- 
age infant  of  three  months  will  not  long  thrive  on  a  food  of  so 
low  a  proteid  proportion  as  the  one  given,  but  it  seems  best,  in 
our  experience,  to  start  with  a  mixture  which  can  reasonably  be 
expected  to  be  well  taken  from  the  first.  Should  a  mixture  such 
as  the  one  here  described  be  assimilated  by  the  child,  the  pro- 
portion of  all  the  elements,  especially  the  proteids,  can  be  steadily 
increased  a  small  quantity  at  a  time,  the  index  in  all  cases  being 
the  increase  in  the  child's  weight,  absence  of  indigestion,  colic, 
and  abnormal  stools.  When  the  child  is  weaned  at  the  end  of 
lactation, — eight  to  ten  months, — the  following  may  be  given  : 

Fat, 4.00  Cream, 8      ounces 

Sugar, 5.00  Milk, 7^       " 

Proteids,    ....        ...  3.00  Lime-water,       .  I       ounce 

Lime-water, 5.00  Water, 3^  ounces 

20    ounces. 


Milk-sugar,  .  .  .  .  3^  drams, 
Or  half  the  quantity  of  granu- 
lated sugar,  a  10  per  cent,  cream 
being  used. 


IO4  FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 

In  a  few  weeks  may  be  prescribed  the  following  : 

Fat,    ..........  4.00  Cream,  ......  8  ounces 

Sugar,     .........  5.00  Milk,      .    .....  8  " 

Proteids,     .....    ...  3.25  Lime-water,      .    .       i  ounce 

Lime-water,  .......  5.00  Water  ......  3  ounces 

20       ounces. 

Sugar  of  milk,  .  .  3  drams, 
Or  half  the  quantity  of  granu- 
lated sugar. 

Or  by— 

Fat,    ..........  4.00  Cream,     .....     8      ounces 

Sugar,    .        .......  4.50  Milk,   ......  12  " 

Proteids,    ........  3.50 

As  the  child  advances  in  age  it  may  take  whole  milk,  preferably 
Pasteurized,  and  later  animal  broths  or  a  small  quantity  of  finely 
hashed  tenderloin  steak  once  a  day.  The  discussion  of  the  amount 
of  food  which  should  be  given  at  any  stated  age  and  the  feeding 
of  older  children  will  be  considered  in  a  subsequent  chapter. 


FEEDING  BY  A  WET-NURSE. 

The  advantage  of  this  method  of  feeding  is  that  the  >infant  gets 
the  benefit  of  being  nourished  by  human  milk  with  all  its  peculiar 
and  valuable  properties.  The  disadvantages  are  that  wet-nurses 
are  somewhat  hard  to  get,  and,  when  procured,  there  is  some 
danger  of  the  child  becoming  infected  with  such  diseases  as 
syphilis,  rickets,  and  tuberculosis.  In  selecting  a  wet-nurse  cer- 
tain facts  must  be  borne  in  mind  :  In  the  first  place,  she  should 
be  subjected  to  a  rigid  examination  and  demonstrated  free  from  all 
taint  of  the  diseases  before  mentioned  or  others.  She  should 
not  be  less  than  twenty-one  years  of  age  and  not  more  than 
thirty-five.  A  very  young  wet-nurse  is  apt  to  be  objectionable, 
partly  from  her  methods  and  habits  of  life,  partly  from  the  fact 
that  the  milk  is  frequently  of  poor  quality,  and,  besides,  as  a 
rule,  she  has  but  little  knowledge  of  the  care  of  children.  It  is 
of  importance  that  her  own  child  should  be  of  about  the  same 
age  as  the  child  she  intends  to  nurse,  although  some  authorities 
consider  it  well  that  the  nurse's  child  be  five  or  six  months 
older  than  the  one  she  is  to  care  for.  She  should  be  in  good 
health,  not  too  fat,  and  of  a  placid  disposition.  Her  breasts 
should  be  of  good  shape,  well  developed,  and  with  good-sized, 
well-formed  nipples.  Before  engaging  a  wet-nurse  it  is  of  great 
importance  that  a  careful  analysis  of  her  milk  be  made,  and  that 
the  latter  be  of  a  quality  equal  to  the  average  standard  of  good 
human  milk. 


FEEDING    BY   THE   USE  OF   MODIFIED    MILK  OF  ANIMALS.       10$ 


FEEDING  BY  THE  USE  OF  MODIFIED  MILK  OF 
ANIMALS. 

In  the  largest  proportion  of  cases  where  the  mother  can  not 
nurse  her  child  from  the  breast,  we  must  find  a  substitute  in  the 
milk  of  the  cow  or  some  other  animal,  either  used  in  its  original 
condition  or  modified  in  some  form  so  as  better  to  adapt  it  to  the 
needs  of  the  infantile  digestive  apparatus,  or  else  use  some  pro- 
prietary food  containing  principally  starch,  dextrin,  or  maltose. 
For  the  purpose  of  feeding  the  human  infant,  cow's  milk  has  the 
greatest  degree  of  practical  utility,  from  the  ease  with  which  it 
can  be  obtained  and  modified  and  on  account  of  its  mechanical 
composition. 

The  milk  of  the  ass  and  of  the  goat  is  considerably  used  by 
the  natives  of  the  countries  in  which  these  animals  are  largely 
raised,  and  is  of  undoubted  use.  For  nutritive  properties  and 
readiness  of  assimilation  ass's  milk  stands  quite  high,  but  the 
difficulty  of  obtaining  it  makes  it  of  little  use  in  this  country. 
An  analysis  of  its  constituents  gives  the  following  result : 

ASS'S  MILK.—  (Peligot.) 


1 

BILKING  INTERVALS 

One  and  a  half 
hours. 

Six  hours. 

Twenty-four 
hours. 

Butter,      

1.55 

1.4. 

1.  2T. 

Sujrar.  . 

•  O3 

6.« 

6.4 

6  « 

Casein,      

•3.4.6 

I.ce 

I  OI 

The  milk  of  the  goat  can  be  quite  easily  obtained,  and  is  useful 
in  certain  cases.  An  analysis  of  a  specimen  made  for  the  authors 
at  the  City  Laboratory  of  Philadelphia  gives  its  composition  as 
follows : 

Fat 5.85  per  cent. 

Albuminoids, 4-49       " 

Milk-sugar,      5.11        " 

Mineral  matter, 0.88       " 

Water 83  67       " 


The  composition  of  cow's  milk  differs  considerably  from  that 
of  the  human  female.  In  the  milk  of  the  cow  the  proportion  of 
proteids  is  much  greater  than  in  human  milk,  while  the  amount 
of  sugar  (lactose)  is  considerably  less.  Fat  is  present  in  about 


IO6     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

the  same  quantity  in  both,  but  its  proportion  to  other  elements 
is  lower  in  cow's  milk  than  in  human  milk.  The  quantities  of  fat, 
sugar,  and  proteids  found  in  cow's  milk  vary  greatly  in  different 
specimens  examined.  Starr  gives  the  comparative  proportions 
of  both  as  follows  : 

SOUND  DAIRY  MILK. 

Reaction, Feebly  acid 

Specific  gravity, 1.0297 

Bacteria, Always  present 

Fats,      3  to  6,         average  3. 75 

Lactosej 3.5  to  5-5>  average  4.42 

Albuminoids, 3  to  6,         average  3. 76 

Ash, 0.6  to  0.9,  average  0.68. 

HUMAN  MILK. 

Reaction, Persistently  alkaline 

Specific  gravity, 1-0313 

Bacteria, Seldom  present 

Fats, 2  to  7,  average  4. 13 

Lactose, 5.4  to  7.9,    average  7 

Albuminoids, 0.85  to  4. 86,  average  2 

Ash, 0.13  to 0.37,  average  o. 2. 

And  Rotch,  in  an  analysis  of  24,000  specimens  of  cow's  milk, 
found  the  following  results  :  ,? 

COW'S  MILK. 

Reaction, Slightly  acid 

Specific  gravity, 1.032 

Water,       86  to  87  per  cent. 

Total  solids 13  to  14       " 

Fat, 4  " 

Milk-sugar, 4.5  " 

Colostrum  is  a  fluid  which  is  secreted  by  the  mammary  gland 
before  the  true  secretion  of  milk  appears.  This  fluid  is  of  a  yel- 
lowish color,  and  contains  more  proteids  and  salts  and  less  sugar 
and  fat  than  ordinary  milk.  It  has  a  specific  gravity  of  1040  to 
1046,  and  a  strongly  alkaline  reaction.  Heat  coagulates  it  into 
solid  masses,  and  it  may  also  coagulate  spontaneously.  Micro- 
scopically, the  fat-globules  are  of  unequal  size,  and  among  them 
will  be  seen  large  granular  bodies  known  as  colostrum  corpuscles. 
These  are  probably  epithelial  cells  which  have  undergone  fatty 
degeneration. 

COMPOSITION  OF  HUMAN  COLOSTRUM.— (Pfeiffer.) 

Proteids, 5.71 

Fat, 2.04 

Sugar, 3.74 

Salts, 0.28 

Water, 88.23 


FEEDING    BY   THE   USE  OF   MO03FJE/I>  M*U£      F  ANIMALS. 


The  colostrum  corpuscles  diminish  in  number  a  few  days  after 
the  birth  of  the  child  and  disappear  in  about  two  weeks.  Colos- 
trum is  generally  considered  to  have  a  laxative  effect  on  the  in- 
testines of  the  new-born  infant. 

A  glance  at  the  foregoing  tables  will  convince  us  that  when- 
ever the  milk  of  the  cow  or  of  another  animal  is  used  for  infant 
feeding,  considerable  modification  will  be  necessary  before  it 
approximates  in  its  composition  human  milk.  If  we  turn  to 
the  list  of  artificial  foods,  we  find  that  in  all  starch,  dextrin,  or 
maltose  is  the  predominating  factor.  Now,  we  know  that  the 
digestive  apparatus  of  the  young  infant  up  to  the  sixth  or 
eighth  month  either  can  not  digest  starch  at  all  or  can  only  do 
so  by  being  forced  ;  therefore  these  foods,  as  a  rule,  should  be 
passed  by,  or,  if  necessity  compels  their  use,  it  should  only  be 
for  a  short  time.  The  human  infant  in  the  first  six  or  eight 
months  of  its  life  needs  a  diet  of  milk,  the  constituents  of  which 
are  all  necessary  to  its  growth.  As  a  rule,  young  children  do 
not  thrive  well  for  a  long  time  on  a  diet  of  starch  or  maltose. 
When  these  foods  are  mixed  with  milk,  their  nutritive  properties 
are  increased,  but  it  is  principally  the  milk  that  nourishes  rather 
than  the  patent  food  which  is  mixed  with  the  milk.  We  are 
compelled  to  acknowledge  that  as  yet  the  best  substitute  to  re- 
place mother's  milk  is  to  be  found  in  the  milk  of  one  of  the 
mammals.  Looking  over  the  analyses  of  the  milk  of  those  ani- 
mals which  are  at  all  available,  we  find  that  the  milk  of  the  cow 
offers  the  most  convenient  source  of  supply,  and  while  it  may 
not,  in  the  proportion  of  its  elements,  approximate  quite  so 
nearly  to  human  milk  as  that  of  some  other  animal,  yet  it  is  easy 
to  obtain  and  is  in  a  high  degree  susceptible  of  satisfactory 
modification. 

Milk  as  a  food  contains  in  a  condensed  form  all  the  elements 
necessary  for  the  sustenance  of  the  young  animal  of  any  species. 
In  it  we  have  the  carbohydrates,  the  element  necessary  for  the 
production  and  maintenance  of  bodily  heat  ;  the  proteids,  which 
are  needed  to  build  up  and  repair  tissue  waste,  and  the  fats, 
which  also  aid  in  the  maintenance  of  the  bodily  heat  and  give 
rotundity  to  the  form.  Along  with  these  we  have  an  amount 
of  earthy  salts  necessary  to  aid  in  cell-formation,  and  particularly 
in  the  building  up  of  the  bony  structures  of  the  body.  Before 
taking  up  the  subject  of  the  adaptation  of  cow's  milk  as  a  sub- 
stitutive  food  for  the  infant,  we  must  consider  for  a  moment  the 
composition  of  human  milk.  As  the  milk  comes  from  the  breast, 
and  before  it  is  contaminated  by  contact  with  the  outer  surface  of 
the  nipple  or  the  child's  mouth,  it  is  an  absolutely  sterile  fluid,  and 


•      •          iiU 


IO3  'FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 

a.  C   i   '"^ 

consists  of  what  is  practically  a  finely  divided  emulsion  of  fat 
and  proteids  (milk  fat  and  casein)  suspended  in  a  weakly  alka- 
line solution  of  salts  and  containing  a  definite  proportion  of  sugar 
(lactose).  This  fluid  is  warmed  to  the  temperature  of  the  body, 
and  in  the  breast  of  a  woman  in  good  health  is  absolutely  free 
from  bacteria.  The  proportion  of  the  various  elements  is  sub- 
ject to  considerable  change,  according  to  the  health  and  habits 
of  the  individual  and  the  period  of  lactation.  Some  authorities 
claim  that  there  is  an  increase  in  the  casein  or  caseinogen  until 
the  second  month,  from  which  time  it  diminishes  until  the  ninth 
month  ;  this,  however,  is  by  no  means  a  constant  rule.  It  is 
possible  that  the  quantity  of  lactose  may  increase  from  the 
second  to  the  eighth  month.  The  liquid  portion  of  the  milk  is 
derived  from  the  blood ;  the  other  properties,  such  as  casein  or 
caseinogen,  fat  and  sugar,  are  the  special  products  of  the  secre- 
tory cells  of  the  mammary  gland.  The  milk  fat,  or  butter,  in 
the  form  of  finely  divided  globules,  is  held  in  suspension  in  the 
liquid  part  of  the  fluid. 

The  period  of  greatest  activity  in  the  secretion  of  milk  is  from 
ten  months  to  a  year  following  the  birth  of  the  child.  In  the 
largest  proportion  of  cases  the  most  abundant  secretion  is  during 
the  first  six  months  of  this  time,  and  at  the  end  of  this  period  the 
quantity  and  quality  of  the  milk  are  at  their  best.  Should  the 
child  die,  or  for  any  reason  be  prevented  from  nursing,  the  secre- 
tion of  milk  rapidly  diminishes  and  disappears. 

Rotch  has  given  the  following  table  showing  the  composition 
of  a  number  of  specimens  of  good  breast  milk  from  the  third  to 
the  ninth  month  of  lactation  : 


I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

Fat,      .... 

Milk-sugar,     . 
Albuminoids, 
Mineral  matter, 

Total  solids, 
Water,     .    .    . 

Parts, 

2.OO 

6.00 

1.  00 

0.17 

2.OO 

6.00 

1.50 

0.25 

2.OO 
7-OO 
1.50 

0.25 

3.00 

6.00 

I.OO 

0.17 

3.50 

6.50 
I.JO 

0.25 

4.00 
6.00 

I.OO 

0.17 

4.00 
6.00 

2.OO 

0.33 

4.00 
7.00 

2.OO 

o-33 

4-50 

7.00 
2.50 
0.41 

9.17 
90.83 

9-75 
90.25 

10-75 
89.25 

10.17 

89.83 

11-75 
88.25 

11.17 
88.83 

12.33 

87.67 

13.33 
86.67 

14.41 

85-59 

100.00 

100.00 

IOO.OO    IOO.OO 

IOO.OO    IOO.OO 

IOO.OO 

IOO.OO 

IOO.OO 

1 

Chemistry  of  Milk. — In  order  to  better  understand  the 
reasons  for  the  necessity  of  modification  of  cow's  milk,  we  must 
consider  briefly  the  various  constituents  of  both  cow's  and 
human  milk,  remembering  always  that  the  elementary  principles 


FEEDING    BY   THE  USE  OF    MODIFIED   MILK   OF  ANIMALS. 

of  both  are  subject  to  very  great  variations  according  to  the 
period  of  lactation  and  the  results  obtained  by  diverse  analyses. 

Fat. — Cow's  milk,  as  a  rule,  contains  about  the  same  amount 
of  fat  as  human  milk.  The  fat  is  a  mixture  of  glycerids  of  the- 
fatty  acids,  the  palmitic,  stearic,  and  oleic,  and  the  glycerids  of 
certain  volatile  acids,  chiefly  butyric  and  others,  such  as  caproic 
and  caprylic.  Over  40  per  cent,  of  the  fat  consists  of  olein. 
Under  the  microscope  the  fat  appears  as  minute,  shining  glob- 
ules ;  these,  in  a  fresh  specimen,  are  uniformly  spread  over  the 
field,  not  being  collected  in  groups.  The  amount  of  fat  in  milk 
will  vary  much  from  time  to  time,  more,  indeed,  than  any  other 
constituent  of  the  fluid ;  as  a  rule,  however,  each  cubic  millimeter 
of  cow's  milk  should  contain  from  2,000,000  to  3,000,000  fat- 
globules.  High  temperature  will  cause  a  partial  separation  of 
the  fat,  which  will  rise  to  the  surface  and  form  butter.  The  per- 
centage of  fat  in  average  cow's  milk  will  range  between  3.5  and 
4  per  cent. 

Sugar. — Sugar  exists  in  milk  in  the  form  of  lactose.  Accord- 
ing to  Leeds,  this  element  occupies  a  peculiar  place  in  the  car- 
bohydrate group  between  cane-sugar  and  starch.  Its  principal 
function  in  the  infant's  body  is  to  supply,  by  oxidation,  the 
normal  heat,  which  can  not  at  this  early  age  be  kept  up  by  loco- 
motion and  general  muscular  action.  Under  the  influence  of 
certain  bacteria,  principally  the  lactic  acid  bacillus,  the  lactose 
is  partly  decomposed  in  the  stomach  and  forms  lactic  acid. 
A  certain  proportion  passes  unconverted  through  the  stomach 
into  the  intestines,  where,  by  the  action  of  the  secretions  of  the 
latter,  it  is  changed  into  glucose,  and  thus  enters  the  portal  cir- 
culation. The  proportion  of  sugar  in  cow's  milk  ranges  from  4 
to  4.5  per  cent.,  whereas  in  human  milk  it  averages  from  6  to  7 
per  cent. 

Proteids. — The  nitrogenous  portion  of  cow's  milk  shows  many 
important  differences  from  that  of  human  milk.  Both  contain 
large  quantities  of  lactalbumin  and  casein  or  caseinogen.  The 
proportion  of  proteids  is  less  in  human  milk  than  in  cow's  milk, 
the  relation  being  about  1.5  per  cent,  in  the  former  and  4 
per  cent,  in  the  latter.  These  proteids  represent  the  nutritive 
elements  of  milk.  They  are  partially  in  solution  and  partially 
in  suspension,  as  is  seen  by  filtering  milk  through  porcelain, 
when  nearly  all  the  caseinogen  is  left  behind  with  the  fat,  while 
a  small  portion  of  the  caseinogen  and  other  products  is  easily 
recognized  in  the  serum.  The  coagulable  proteids  in  cow's 
milk  exist  in  a  comparatively  larger  amount  than  in  human  milk, 
so  that  under  the  same  conditions  a  larger  curd  will  be  found  in 


IIO     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

the  former  than  in  the  latter.  The  casein  of  cow's  milk  can  be 
precipitated  into  the  form  of  coagula  by  the  addition  of  dilute 
acetic  acid  or  by  saturating  with  a  solution  of  sulphate  of  mag- 
nesia. Precipitation  of  the  casein  can  also  be  made  by  adding 
rennet  to  cow's  milk,  when  this  substance  is  thrown  down  in  the 
form  of  soft,  dense  flakes.  Human  milk  requires  much  more 
acetic  acid  to  extract  the  casein  than  does  cow's  milk,  and  when 
the  precipitation  takes  place,  the  casein  does  not  occur  in  lumps, 
but  as  a  fine  powder  which  dissolves  in  an  excess  of  acetic  acid. 
The  lactalbumin  remains  in  a  solution  as  whey  after  separation 
of  the  casein,  and  is  rendered  insoluble  by  boiling ;  it  is  said  to 
resemble  closely  serum  albumin  (Leeds). 

Inorganic  salts  found  in  the  ash  of  milk  contain  principally 
the  salts  of  lime,  potassium,  and  sodium,  usually  in  combination 
with  chlorin  and  phosphoric  acid.  The  following  table  repre- 
sents the  relation  existing  between  the  inorganic  salts  in  cow's 
milk  and  human  milk  : 

Cow's  MILK.  HUMAN  MII.K. 

Potash 24.5  o.  18  33.78  0.07 

Soda, II  o.  II  9.16  0.03 

Lime, 22.5  o.  16  16.64  0.03 

Magnesia, .    2.6  0.02  2.16  o.oi 

Oxid  of  iron, 0.3  0.0004  °-25  '0.0006 

Phosphoric  acid,       26  0.2  22.74  0.05 

Sulphuric  acid, I  1.89 

Chlorin, 15.6  0.17  18.38  0.04 

Reaction. — Human  milk  as  it  comes  from  the  breast  is  invari- 
ably slightly  alkaline  in  reaction.  Cow's  milk,  on  the  contrary, 
has  a  somewhat  acid  reaction,  and  Rotch  states  that  this  is 
the  case  whether  the  milk  has  been  tested  directly  from  the 
udder  or  has  stood  for  twenty-four  hours.  Milk  also  contains 
small  quantities  of  urea  and  citric  acid. 

DECOMPOSITION  AND  BACTERIOLOGY  OF  MILK. 

Except  in  cases  of  local  disease,  human  milk  is  usually  con- 
sidered sterile,  and  there  is  no  doubt  that  so  far  as  the  milk  within 
the  mammary  gland  goes  this  is  the  case,  as  has  been  shown  by 
the  researches  of  Escherich,  who  examined  the  milk  of  twenty- 
five  healthy  women  and  found  it  absolutely  •  without  bacteria. 
Cohn  and  Neumann,  on  the  other  hand,  found  .micro-organisms 
in  the  milk  of  forty-three  out  of  forty-eight  healthy  women. 
The  varieties  of  bacteria  most  generally  present  were  the  staphy- 
lococcus  pyogenes  albus  and  staphylococcus  pyogenes  aureus 
and  the  streptococcus  pyogenes.  Ringel,  having  examined  the 
milk  of  twelve  healthy  and  thirteen  unhealthy  nursing  women, 


DECOMPOSITION    AND    BACTERIOLOGY  OF    MILK.  I  I  I 

found  it  sterile  in  three.  Honigman  reports  that  in  seventy-six 
examinations  of  the  milk  of  sixty-four  women  recently  confined 
he  found  it  sterile  in  only  four  cases.  The  above-named  bacteria 
were  the  ones  most  generally  present.  The  number  of  micro- 
organisms in  human  milk  varies  much  as  to  whether  the  specimen 
is  from  the  first  milk  drawn  of  from  that  contained  within  the 
gland,  the  number  of  bacteria  being  much  greater  in  the  milk 
which  first  comes  from  the  nipple  than  that  within  the  milk-ducts. 
The  milk  last  drawn  from  the  breast  is  usually  quite  sterile. 

Milk  in  the  udder  of  the  cow  is  practically  sterile,  but  as  soon 
as  it  is  drawn  the  germs  of  decomposition  can  be  found  in  it, 
although  the  utmost  care  in  all  details  has  been  employed. 
Some  bacteria  are  present  in  newly  drawn  milk.  The  barn,  the 
cow,  the  milker,  the  hay  on  which  the  cow  is  fed,  the  bedding  upon 
which  she  lies,  the  dust  of  the  roads,  from  decaying  vegetables, 
the  common  molds  of  cheese  and  bread,  the  ferment  of  butter- 
making  even,  to  say  nothing  of  the  more  extraordinary  forms  of 
bacteria,  all  have  more  or  less  effect  in  producing  decomposition 
of  milk.  When  milk  is  simply  sour,  it  is  because  the  common 
lactic  acid  bacteria  have  done  their  natural  work  upon  the  sugar. 
When  milk  is  bitter  and  the  curd  separates  in  cloudy  masses,  it 
is  because  the  so-called  "  lab-"  ferments  have  acted  upon  the 
proteids.  When  milk  is  what  is  known  as  "  blue  "  (though  this 
must  be  carefully  distinguished  from  blueness  of  common  skimmed 
milk),  it  is  because  certain  foreign  bacteria  have  found  their  way 
into  it.  When  milk  is  very  red  from  causes  other  than  the  pres- 
ence of  blood,  there  is  reason  to  suspect  a  very  dangerous  form 
of  contamination.  Ropy  or  stringy  milk  is  probably  the  vehicle 
for  some  of  the  pyogenic  bacteria  or  their  products.  Some  of 
these  sources  of  decomposition  are  derived  from  the  farm  and 
dairy.  Many  are,  however,  supplied  plentifully  by  any  ordinary 
kitchen,  refrigerator,  the  air  of  the  nursery,  and  the  unclean  con- 
dition of  vessels  employed  in  the  home.  The  only  way  to  obtain 
a  perfect  milk  is  to  produce  it  in  a  scientific  way  and  to  employ  all 
aseptic  and  antiseptic  precautions  necessary  for  its  protection 
against  contamination.  For  this  purpose  cold  and  heat  are  the 
means  which  can  most  conveniently  be  used  to  keep  a  good  milk 
as  nearly  perfect  as  is  possible.  A  temperature  below  40°  F. 
(4.4°  C.)  prevents  the  growth  of  the  few  bacteria  that  the  very 
best  must  contain.  Heat  will  kill  most  bacteria  and  all  the 
pathogenic  milk  forms  commonly  met.  It  is  probable  that  a 
temperature  of  156°  F.  (68.9°  C.)  will  render  a  milk  safe  for  use, 
but  it  is  seriously  doubted  whether  heat  can  render  an  impure 
milk  nutritious.  It  is  certain,  however,  that  a  perfect  milk  will 


112 


FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 


remain  so  for  an  indefinite  time  at  35°  F.  (1.6°  C.)  ;  at  this  tem- 
perature also  a  pure  and  good  milk  will  remain  unchanged  for  a 
sufficient  time  for  dietetic  purposes. 

Sedgewick  and  Batchelder  give  the  following  figures  to  show 
the  enormous  number  of  bacteria  present  in  ordinaiy  cow's  milk 
such  as  is  served  to  consumers  : 

1.  There  were  67,143   micro-organisms  in  a  cubic  centimeter 
found  in  samples  of  milk  from  the  tables  of  persons  in  the  suburbs 
of  Boston  in  an  average  of  fifteen  examinations. 

2.  Over  250,000   in  a  cubic   centimeter  were   found   in  milk 
taken  directly  from  the  milk-carts  in  Boston  in  an  average  of 
fifty-seven  examinations. 

3.  Over  4,500,000  in  a  cubic  centimeter  were  found  in  milk 
obtained    from    Boston   groceries.      It    is    stated    that    in    milk 
obtained  from  the  milk-houses  in  London  in  1896  the  number 
varied  from  848,400  to  8,119,200  in  a  cubic  centimeter.      Renk 
found  from  6,000,000  to  30,000,000  in  a  cubic  centimeter  in  the 
milk-supply  of  Halle. 


THE  PERCENTAGE  COMPOSITION  OF  COW'S  MILK  AT  DIFFERENT 
STAGES  OF  THE  MILKING.— (Harrington.) 


WATER. 

SOLIDS. 

FAT. 

ASH. 

Fore  milk,     .        .... 

86.66 

I  "I.  -IA. 

3  88 

o  85 

Middle  milk,     

84.6 

I"v  4 

6.74. 

0.81 

Strippings     ...        .    . 

82  87 

17  I? 

8   12 

o  82 

THE    PERCENTAGE   COMPOSITION   OF   FORE   MILK   AND 
STRIPPINGS.— (  Wynter  Blyth.} 

(Specimens  taken  from  two  cows  of  different  breeds.) 


DEVON  Cow. 

GUERNSEY  Cow. 

Fore  Milk. 

Strippings. 

Fore  Milk. 

Strippings. 

Water  

90.319 
9.681 
4098 
2.387 
1.83 
0.381 
I.I66 
3.12 

0-797 
1.0288 

83-94 
1  6.  06 
5.824 
4.304 
0-975 
0-545 
5.8i 

3-531 
0.895 
1.0256 

88.4 
II.  6 

5.426 
4-708 
0.451 
0.207 
0-357 
4-943 
0.874 
1.04 

83-394 
16.604 

4-451 

3-435 
0.86 
0.156 
5-946 
5-28 
0.929 
1.023 

Solids,       

Proteids,    

Casein,           .... 
Albumin,  ..... 

Peptones,      .... 
Fat,    

Sugar.    . 

Ash  

Specific  gravity,    .... 

DECOMPOSITION    AND    BACTERIOLOGY    OF    MILK.  I  I  3 

Examination  of  Milk. — An  analysis  of  the  mother's  milk 
should  be  made  in  all  cases  in  which  an  attack  of  indigestion 
appears  in  a  breast-fed  infant.  It  is  often  necessary  to  test  cow's 
milk  in  order  to  be  sure  that  the  specimen  used  in  infant  feeding 
is  of  standard  quality.  In  making  an  examination  of  a  sample 
of  human  milk  it  is  of  great  importance  to  obtain  the  entire  milk 
secreted  at  one  nursing,  or,  when  this  is  impossible,  it  is  generally 
advised  that  a  portion  of  middle  milk  should  be  taken.  The 
quality  of  the  milk  both  of  the  human  female  and  of  the  cow  will 
vary  greatly  during  the  emptying  of  the  milk-glands,  and  on  this 
account  an  examination  of  any  one  portion  will  prove  unsatis- 
factory. The  milk  which  is  first  drawn  from  the  nipple  is  usually 
known  as  "  fore  milk."  This  contains  a  much  larger  percentage 
of  water  and  a  lower  percentage  of  fat  than  does  the  bulk  of  the 
milk  which  is  in  the  milk-glands.  The  last  milk  drawn  is  known 
as  "stoppings  ";  it  contains  less  water  and  a  higher  percentage 
of  solids  and  fats  than  does  middle  milk.  The  term  "  middle 
milk  "  is  applied  to  the  bulk  of  the  milk  which  is  in  the  mammary 
gland.  The  tables  on  page  112  will  show  the  differences  in 
composition  of  the  three  grades  of  milk. 

PERCENTAGE  OF  TOTAL  SOLIDS  IN  HUMAN  MILK.— (Reiset.) 

BEFORE  SUCKLING.  AFTER  SUCKLING. 

i, 10.58  12-93 

2, 12.78  I5-52 

3. 13-46  14-57 

A  certain  general  idea  in  regard  to  the  quantity  and  quality 
of  the  milk  secreted  may  be  had  from  the  inspection  of  the 
breasts  and  from  studying  the  manner  in  which  the  infant  nurses. 
When  the  time  spent  in  nursing  is  long,  say  from  thirty  to  fifty 
minutes,  the  probabilities  are  very  strong  that  the  quantity  is  too 
small.  On  the  other  hand,  if  the  breasts  are  conic  in  shape, 
hard,  and  full,  the  supply  is  probably  abundant.  A  soft,  flabby 
breast  indicates  a  deficient  supply  of  milk,  and  when  noticed  in 
combination  with  a  prolonged  period  of  nursing,  the  quantity  of 
milk  is  almost  certainly  scant.  Another  method  of  testing  the 
quantity  of  milk  is  to  weigh  the  infant  before  and  after  nursing. 
This  method  would  require  very  accurate  scales,  and  is  not 
always  satisfactory.  The  quantity  can  also  be  measured  by 
pumping  the  breasts  at  regular  intervals  throughout  a  given  time, 
and  estimating  from  this  the  amount  secreted  in  twenty-four 
hours.  The  specific  gravity  is  usually  taken  by  means  of  a  small 
hydrometer  which  should  be  graduated  from  1010  to  1040. 

An  increase  in  the  proportion  of  fat  represented  by  the  cream 
lowers  the  specific  gravity  of  the  whole  milk.  The  specific  grav- 
8 


FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 


ity  increases  with  the  proportion  of  other  solid  matter.  The 
reaction  of  milk  can  be  tested  with  ordinary  litmus  paper. 

Microscopic  Examination. — By  means  of  the  microscope  we 
can  determine  in  milk  the  size  and  division  of  the  fat-globules, 
the  presence  or  absence  of  colostrum  corpuscles,  and  the  pres- 
ence or  absence  of  blood,  pus,  or  epithelium.  The  colostrum 
corpuscles  are  not  generally  found  in  milk  after  the  twelfth  day. 

The  estimation  of  fat  can  be  made  as  folloivs :  The  glass  cylinder 


1.010 
1.020 
1,036 
1,010 


\ 


A  B  C 

FIG.  15. — A.  MARCHAND'S  TUBE.    B,  C.  HOLT'S  LACTOMETER  AND  CREAM  GAGE. 

of  the  cream  gage  (see  C,  Fig.  1 5),  which  holds  ten  cubic  centi- 
meters, is  filled  to  the  zero-mark  with  freshly  drawn  milk.  This 
should  be  allowed  to  stand  at  the  temperature  of  the  room — that 
is,  from  66°  to  72°  F.  (18.9°  to  22.2°  C.) — for  twenty -four  hours, 
at  the  end  of  which  time  the  amount  of  cream  is  read  off.  The 
proportion  of  cream  bears  a  relation  to  the  proportion  of  fat  con- 
tained in  it  as  5  is  to  3.  Thus,  5  per  cent,  of  cream  will  indicate 
that  the  milk  contains  3  per  cent,  of  fat.  A  more  accurate  de- 
termination of  the  actual  amount  of  fat  can  be  obtained  by  the 
use  of  the  Babcock  centrifugal  machine.  By  this  method  the  fat 


DECOMPOSITION*    AND    BACTERIOLOGY    OF    MILK. 


ii ; 


Fat* 
7 


4  CO* 


is  brought  to  the  surface  by  centrifugal  action  ;  previous  to  this 
the  nitrogenous  principles  have  been  destroyed  by  sulphuric  acid. 

Another  test  is  by  the  use  of  Feser's  lactoscope.  (See  Fig.  16.) 
This  test  is  made  as  follows  :  Four  cubic 
centimeters  of  milk  are  measured  off  in  a 
pipet,  put  into  a  tube,  and  water  slowly 
added,  shaking  from  time  to  time  until  the 
black  lines  of  the  porcelain  stem  at  A  are 
clearly  visible  through  the  mixture  of  milk 
and  water.  The  percentage  of  fat  is  then 
read  off  on  the  glass  cylinder  at  the  level  of 
the  water  added  ;  thus,  if  the  water  is  to 
the  mark  4,  it  indicates  the  presence  of  4 
per  cent,  of  fat.  This  test  is  only  applic- 
able to  cow's  milk. 

The  test  by  the  use  of  Marchand's  tube 
(see  A,  Fig.  15)  may  also  be  used.  This 
test  can  be  made  in  the  following  manner : 
Five  cubic  centimeters  of  milk  are  first 
poured  into  the  tube  so  as  to  fill  it  to  the 
line  M,  after  which  four  or  five  drops  of 
liquor  sodae  are  added  ;  the  mixture  is  well 
shaken,  and  five  cubic  centimeters  of  ether 
are  inserted  so  as  to  bring  the  mixture  to 
the  line  E.  The  tube  is  now  corked  and 
shaken  fifteen  to  twenty  times,  after  which 
it  is  filled  to  the  line  A  with  96  per  cent, 
alcohol.  The  tube  should  now  be  tightly 
stoppered  and  shaken  thoroughly,  after 

which  it  is  placed  upright  in  a  tall  bottle  containing  water  at  a 
temperature  of  120°  to  150°  F.  (48.9°  to  65.6°  C).  The  fat 
separates  and  forms  a  distinct  layer  at  the  top,  and  after  half 
an  hour  the  amount  can  be  read  off  in  degrees. 

The  percentage  of  fat  represented  by  each  degree  of  the  in- 
strument can  be  seen  in  the  following-  table  : 


FIG.  16. — FESER'S 
LACTOSCOPE. 


DEGREES,  MARCHAND. 

PERCENTAGE  OF 
FAT. 

DEGREES,  MARCHAND. 

PERCENTAGE  OF 
FAT. 

I 
3 

1.49 
1.96 

13 
15 

4.29 
4-75 

5 
7 
9 

2.42 
2.89 
3-36 

17 
19 

21 

5.22 
5.68 
6.14 

ii 

3-82 

n6 


FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 


Each  additional  degree  on  the  tube  corresponds  to  0.23  per 
cent,  of  fat. 

Another  test  for  the  fats  of  milk  may  be  made  as  follows :  Five 
cubic  centimeters  of  milk  are  put  in  a  stoppered  tube  graduated 
to  50  c.c.,  and  shaken  up  with  10  c.c.  of  strong  hydrochloric 
acid.  Next,  place  in  a  hot- water  bath  until  the  mixture  turns 
dark  brown  in  color,  this  change  being  due  to  the  conversion  of 
lactose  into  maltose;  it  will  again  become  clear  except  for  a 
small  amount  of  floating  coagulum  of  lactalbumin.  It  is  then 
cooled  under  the  tap,  and  when  cold,  35  c.c.  of  ether  are  added. 
The  mixture  is  now  well  shaken  up  for  a  few  minutes  and  allowed 
to  stand.  In  fifteen  minutes  the  fluid  will  be  seen  to  consist  of 
three  layers — an  upper  clearer  layer  of  ether  containing  fat ;  a 
lower  clearer  layer  of  acid  albumin,  water,  etc.  ;  and  a  narrow, 
intermediate  flocculent  white  layer,  about  half  an  inch  thick,  of 
coagulated  albumin.  Read  off  the  depth  of  the  ether  layer  from 
the  50  c.c.  mark  to  the  middle  of  the  layer  of  coagulated  albu- 
min. Then  measure  off  rapidly  two  portions  of  10  c.c.  each, 
taken  from  the  ether  layer,  into  platinum  capsules  which  have 
previously  been  weighed.  Place  these  in  a  hot  incubator,  and 
when  the  contents  have  been  converted  to  dryness,  they  should 
be  weighed.  Take  the  mean  of  the  two  estimations,  and  from 
that  calculate  the  weight  of  fat  in  the  lower  ether  layer  :  that 
is,  of  the  5  c.c.  of  milk  under  examination.  Multiply  by  twenty 
to  obtain  the  weight  of  the  fat  in  100  c.c.  of  milk  (Schmidt's 
method). 

Cream. — Cream  must  be  regarded  as  milk  which  contains  an 
excess  of  fat  (Holt).  Cream  is  obtained  in  one  of  three  ways  : 
by  skimming,  by  the  gravity  process,  and  by  the  use  of  a  centrif- 
ugal machine  or  separator.  With  a  given  specimen  of  milk,  the 
faster  the  separator  is  run,  the  denser  will  be  the  cream.  The 
following  table  will  show  the  proportions  of  the  various  con- 
stituents of  separator  cream  of  four  different  densities  as  com- 
pared with  good  cow's  milk  : 


WHOLE  MILK. 

CREAM. 

I. 

II. 

III. 

IV. 

Proteids,  .... 
Fat,       .... 

4 
4 
4-3 
0.7 

3-9 
8 

4-3 
0.7 

3-8 

12 

4.2 
0.64 

3-6 
16 

4 
0.6 

3-2 

20 
3-8 
0-55 

Sugar.  . 

Salts,     

DECOMPOSITION    AND    BACTERIOLOGY    OF    MILK.  117 

Cream  is  known  by  the  percentage  of  fat  it  contains  ;  thus,  in 
column  I,  the  figure  8  represents  an  8  percent,  cream  ;  in  column 
II,  12  represents  a  12  per  cent,  cream,  etc.  The  best  centrifugal 
cream  contains  from  25  to  40  percent,  of  fat.  The  reduction  of 
proteids  in  cream  as  compared  with  milk  is  but  slight,  being  less 
than  I  per  cent.  Cream  may  be  obtained  by  the  gravity  process 
as  follows  :  Put  one  quart  of  average  milk  into  a  glass  jar. 
This  jar' must  be  placed  in  iced  water  for  four  or  five  hours,  at 
the  end  of  which  time  it  will  be  found  that  about  ten  ounces  of 
cream  can  be  taken  from  the  top  of  the  jar.  Cream  raised  in  this 
manner  will  contain,  on  an  average,  about  8  per  cent,  of  fat.  If 
the  jar  is  allowed  to  remain  untouched  for  six  hours,  about  six 
ounces  of  1 2  per  cent,  cream  can  be  taken  off.  The  cream  may 
be  removed  by  skimming,  or,  what  is  more  usually  done,  the 
milk  at  the  bottom  of  the  jar  is  siphoned  off,  leav- 
ing the  cream  still  in  the  jar. 

Another  method  of  separating  cream  is  by  the 
use   of  the   Cooley  creamer.     This   consists   of  a 
wooden   tank   lined   with   metal,  and  of  sufficient 
size  to  hold  two  or  more  cans  of  milk.     The  cans 
hold  eighteen  quarts  and  are  so  covered  that  they 
can  be  submerged.     The  bottom  of  each   can  is 
inclined,  and  at  the  lowest  point  of  the  incline  is 
placed  a  faucet.     A  small  piece  of  glass  is  inserted 
into  the  side  of  the  can,  so  that  the  level  attained          FIG.  17. 
by  the   cream  can  be  seen.     The  cans  are   filled      OJ^OIEAM. 
and   placed  in    the   tank  of  iced  water.      At  the 
end  of  six  or  twelve  hours  the  lower  portion   of  the   milk  is 
drawn    off  and  the   upper  layer,  containing  the  cream,  remains 
in  the  can.     By  this  process  any  percentage  of  cream  can  be 
obtained.      The    percentages  most    commonly  used  are  8,    12, 
and  1 6. 

Estimation  of  Lactose. — Dilute  10  c.c.  of  thoroughly  mixed 
milk  with  50  c.c.  of  distilled  water  and  add  dilute  acetic  acid. 
Filter  off  the  precipitated  caseinogen,  mash  up,  and  wash  the 
precipitate  two  or  three  times  with  water,  and  add  the  washings 
to  the  filtered  precipitate.  Raise  this  precipitate  up  to  a  known 
quantity,  say  200  c.c.  Place  this  in  a  buret,  and  estimate  by 
means  of  a  standard  Fehling's  solution. 

Estimation  of  Salts  of  Milk. — To  make  this  test  take  a  plati- 
num capsule  containing  the  dried  salts  of  milk,  and  heat  it  until 
all  the  contents  are  incinerated  and  only  a  white  ash  remains. 
Care  should  be  taken  not  to  heat  the  capsule  to  redness,  other- 
wise small  portions  of  the  salts  may  be  volatilized. 


Il8     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

Estimation  of  Proteids. — The  estimation  of  the  proteids  in  milk 
can  only  be  determined  in  a  general  way.  The  following  rules 
will  give  some  idea  of  the  relative  quantity  present.  If  the 
quantities  of  sugar  and  salts  are  so  nearly  uniform  as  not  to 
affect  the  specific  gravity,  an  approximate  estimation  of  the 
proteids  may  be  made  after  having  obtained  the  specific  gravity 
and  the  percentage  of  fat.  The  specific  gravity  will  vary  directly 
with  the  proportion  of  proteids,  and  inversely  with  the  proportion 
of  fat,  or,  in  other  words,  when  the  percentage  of  proteids  is 
high,  the  specific  gravity  will  also  be  high.  When  the  propor- 
tion of  fat  is  high,  the  specific  gravity  will  be  low. 

In  endeavoring  to  estimate  the  proteids  the  specimen  of  milk 
used  should  be  either  from  the  whole  quantity  secreted  in  the 
breast  during  a  given  time  or  a  specimen  of  middle  milk. 

Effect  of  Drugs  on  Mother's  Milk. — While  it  has  not  been 
proved  that  all  drugs  are  eliminated  in  part  through  the  milk, 
yet  a  certain  number,  undoubtedly,  are  partially  excreted  in  this 
manner.  Their  effect  is  usually  more  noticeable  in  poor  milk 
than  in  milk  of  good  quality.  Among  the  drugs  which  particu- 
larly affect  milk  are  the  following  : 

Mercury. — The  effect  of  this  substance  upon  the'  milk  is  very 
slight  except  after  long  administration,  and  even  then  it  is  very 
doubtful  whether  its  action  is  sufficient  to  be  of  any  impor- 
tance. 

Opium. — It  is  possible  that  opium  may  be  excreted  in  the 
milk  in  sufficient  quantities  to  produce  symptoms  of  poisoning  in 
an  infant.  Its  effects  are  more  noticeable  when  the  quality 
of  the  milk  is  poor.  Holt  states  that  a  fatal  case  has  been 
recorded. 

Belladonna. — It  is  possible  for  this  drug  to  cause  quite  marked 
symptoms  in  the  child  when  administered  to  the  mother  in  full 
doses. 

Potassium  lodid. — This  drug  may  produce  its  effect  upon  the 
child  through  the  mother. 

Saline  cathartics  undoubtedly  affect  the  child  when  admin- 
istered to  the  mother. 

lodoform. — When  applied  externally  to  the  mother,  this 
drug  may  be  found  in  the  urine  of  the  child  in  the  form  of 
iodin. 

Arsenic  and  antimony  have  been  found  in  the  milk  after  their 
administration  to  the  mother. 

Morphin  in  medicinal  doses  is  eliminated  as  apomorphin  in 
the  mother  (Pinani).  This,  however,  has  been  doubted  by  sev- 
eral observers. 


VARIETIES    OF    MILK    FOR    INFANT    FEEDING.  119 


THE  BREEDS  OF  COWS  BEST  ADAPTED  FOR 
INFANT  FEEDING. 

There  does  not  seem  to  have  been  much  opportunity,  either 
here  or  in  Europe,  for.  scientific  conclusions  as  to  the  distinct 
advantage  to  be  gained  by  the  use  of  any  particular  breed  of 
cows  for  infant  feeding  ;  but  clinically  there  appear  to  be  well- 
established  ideas  to  the  effect  that  certain  breeds  of  cows  are 
better  adapted  than  others  for  this  purpose.  Chemists  have  de- 
cided that  the  fats  in  the  milk  of  the  Channel  Islands  cows,  and 
of  one  or  two  similar  breeds  found  upon  the  Continent  of 
Europe,  contain  a  smaller  proportion  of  the  fixed  and  insoluble 
glycerids  of  the  fatty  acids  and  a  larger  proportion  of  the  vola- 
tile and  soluble  glycerids  than  the  milk  of  other  breeds.  As 
the  volatile  glycerids  are  more  readily  decomposed  than  the 
others  and  are  richer  in  those  elements  which  are  found  in  the 
fat  of  nuts,  it  may  be  that  this  is  the  explanation  of  the  less 
digestibility  of  these  milks,  both  for  the  calf  and  for  the  baby. 
It  seems  probable  that  the  best  cow  to  employ  as  a  foster-mother 
for  the  infant  should  belong  to  a  breed  that  invariably  and  suc- 
cessfully raises  its  own  young.  Of  these,  the  Durhams,  Devons, 
Ayrshires,  Holsteins,  and  similar  hardy  breeds  are  favorably 
distinguished.  Then,  also,  the  vigor  of  constitution  of  the  breeds 
of  cattle  and  their  ready  and  perfect  acclimatization  are  also 
potent  reasons  why  these  hardy  breeds  should  be  preferred  to  the 
more  delicate  ones.  The  milk  of  cows  possessing  a  fat  in  the 
most  perfect  emulsion  and  with  the  smallest  fat-globules  is  more 
easily  digested  than  the  milk  of  such  cows  as  the  Jersey  breeds, 
in  which  fat-globules  are  large  and  easily  "creamed"  or  sepa- 
rated from  the  body  of  the  milk-serum.  Besides  the  peculiari- 
ties in  the  fats  already  referred  to,  there  are  other  differences  in 
the  milks  of  various  breeds  of  cows  which  may  influence  their 
value  as  a  food  for  infants.  For  example,  the  proportion  of  fats 
to  proteids  is  of  importance,  especially  when  home  modification 
is  principally  employed.  Thus,  the  3  per  cent,  proportion  of 
fat  of  the  milk  of  the  Holstein  (as  compared  with  the  4  per  cent, 
of  fat  of  the  better  Durhams),  when  it  appears  in  a  milk  con- 
taining over  4  per  cent,  of  proteids,  makes  the  latter  more  diffi- 
cult to  modify  than  does  the  milk  containing  the  larger  amount 
and  richer  quality  of  fat — /.  e.,  the  milk  of  the  Durham.  The 
character  in  the  emulsion  of  the  fat  in  the  milk  of  various  breeds 
of  cows  is  an  important  matter.  The  milk  of  the  Holstein 
holds  its  fine  fat-globules  in  a  very  perfect  emulsion,  and  separa- 


I2O     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

tion  by  gravity,  which  is  the  manner  most  commonly  used  at 
home,  is  slow  and  less  perfect.  On  the  other  hand,  when  milk 
is  used  in  the  nursery  in  an  unmodified  condition,  it  is  always 
safer  to  use  a  milk  that  has  a  perfect  emulsion  of  the  fats,  so 
that  when  it  is  set  aside  for  the  raising  of  cream  by  gravity,  the 
results  are  less  varying  and  uncertain.  The  tendency  to  disease 
among  the  different  breeds  is  slightly  against  the  Jerseys  and 
Guernseys,  especially  upon  the  Atlantic  seaboard. 

•  The  Care  of  the  Cow. — The  cow  whose  milk  is  to  be  used 
for  infant  feeding  should  be  cared  for  with  this  object  only  in 
view.  Her  stabling  should  be  apart  from  other  animals.  Her 
food  should  be  specially  selected,  and  the  water  she  drinks 
should  be  perfectly  pure.  She  should  be  fed  for  the  production 
of  a  digestible  milk,  and  consequently  the  cow  that  makes  the 
most  butter  from  a  given  method  of  diet  is  not  likely  to  be  avail- 
able for  the  feeding  of  a  baby.  A  cow  whose  milk  is  intended 
for  the  use  of  infants  should  be  groomed  once  or  twice  a  day, 
protected  from  annoyances  and  frights,  and  generally  treated  as 
a  member  of  the  family.  She  needs  sunlight,  opportunity  for 
open-air  exercise,  afresh-air  space  of  1000  cubic  feet,  80  square 
feet  of  floor  space,  and  1 2  square  feet  of  window  all  to  herself. 
Her  bedding  must  be  dry  and  clean — if  possible,  all  dry  mill- 
shavings  or  sawdust.  She  should  be  fed  twice  a  day  with  good 
hay  and  grain,  such  as  wheat-bran,  ground  oats,  cornmeal,  etc., 
which  have  been  ground  or  treated  only  by  mechanical  processes. 
She  should  never  be  fed  with  any  of  the  by-products  of  the 
brewery  or  glucose  factory.  A  certain  amount  of  some  succu- 
lent food  should  be  given  her  every  day  ;  thus,  in  the  winter  she 
should  receive  a  measured  quantity  of  sugar  beets  and  carrots, 
and  in  summer  an  abundance  of  carefully  grown,  absolutely 
freshly  cut  green  clover,  alternating  with  green  oats,  green  peas, 
green  sweet  corn,  and  the  meadow  grasses.  She  should  never 
be  permitted  to  range  the  ordinary  pastures  of  the  farms  in  the 
second  half  of  the  summer,  as  many  of  the  prevalent  weeds  then 
growing  are  distinctly  injurious.  From,  the  third  to  the  eighth 
or  ninth  year  of  her  life  is  perhaps  the  best  period  for  the  pro- 
duction of  milk  upon  which  to  feed  an  infant.  It  is  probable 
that  she  should  bear  a  calf  once  a  year.  It  has  not,  however, 
been  shown  as  yet  that  the  prolonged  lactation  of  a  castrated 
cow  is  injurious  to  the  milk  intended  for  infant  feeding.  The 
milk  should  not  be  used  until  it  is  quite  free  from  colostrum,  nor 
should  it  be  used  in  any  advanced  stage  of  gestation.  It  is 
probable  that  the  catamenial  period  in  a  cow  may  render  the 
milk  for  that  day  injurious  to  the  infant,  although  in  large  herds 


CARE    OF    MILK    USED    FOR    INFANT    FEEDING.  121 

it  is  probable  that  this  occurrence  may  have  no  practical  bearing 
on  the  use  of  the  milk,  but  this  word  of  caution  is  necessary  if 
the  infant  is  to  be  fed  from  the  milk  of  a  single  cow.  The  milk 
from  cows  used  for  infant  feeding  should  be  weighed  accurately 
both  morning  and  night,  and  a  difference  of  a  single  pound  at 
milking  is  probably  an  evidence  that  the  cow  is  out  of  sorts. 
This  is  one  of  the  best  guides  for  the  inexperienced  on  this  ques- 
tion. The  cow  for  infant's  use  should  have  the  constant  supervi- 
sion of  a  veterinarian,  because  perfect  health  in  her  is  absolutely 
essential  to  the  well-being  of  the  infant. 

The  Care  of  the  Milk. — The  milker's  hands,  arms,  and  finger- 
nails before  beginning  work  should  be  well  scrubbed  with  hot 
water  and  soap  for  five  minutes  and  rinsed  in  running  water. 
They  should  then  be  scrubbed  in  a  solution  of  borax,  glycerin, 
and  water,  or  with  a  small  quantity  of  alcohol.  This  should  be 
done  before  each  milking.  The  pail  in  which  the  milk  is  re- 
ceived should  be  absolutely  clean  and  sterilized  with  boiling 
water  or  live  steam.  The  milker  should  dress  in  a  freshly  boiled 
and  rough-dried  suit  of  cotton  cloth,  or,  as  is  the  custom  with 
very  careful  dairymen,  the  milker's  clothes  should  be  sterilized 
in  a  closet  in  which  circulates  live  steam  and  which  is  built  ex- 
pressly for  the  purpose.  The  milk,  as  soon  as  drawn  and  while 
still  hot,  should  be  filtered  through  sterile  surgical  cotton,  then 
immediately  cooled  to  a  temperature  below  50°  F.  (10°  C.), 
after  which  it  is  put  in  sterilized  glass  jars  and  kept  in  a  clean, 
cold  place  until  it  is  wanted  for  use.  The  milkers  should  be 
healthy  men,  living  in  healthy  houses,  and  should  be  intelligent 
enough  to  understand  the  reasons  and  importance  of  perfect 
cleanliness.  As  precautionary  measures  are  necessary  against 
the  well-known  infectiousness  of  milk,  especially  contamination 
from  outside  sources,  the  water  in  which  vessels  are  washed  and 
rinsed  should  be  isolated  from  all  possibility  of  infection  and  all 
vessels  and  tools  used  in  the  dairy  should  be  sterilized  with  live 
steam  after  rinsing.  All  manipulation  of  the  milk  should  be  done 
in  a  place  separated  entirely  from  the  barn  and  in  which  the 
atmosphere  is  kept  free  from  dust  and  odors. 


SUPERVISION  OF   THE    PRODUCTION   OF  MILK  BY 
BOARDS  OF  HEALTH. 

The  majority  of  the  States  of  the  Union  have,  through  their 
State  boards  of  health,  given  much  attention  to  improvement  in 
the  milk-supply,  and  in  a  general  way  this  authority  is  exercised 


122     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN'. 

in  two  principal  directions  :  first,  in  the  stamping  out  of  certain 
infectious  diseases  prevalent  among  cows,  and  second,  in  induc- 
ing the  better  management  of  barns  and  dairies.  The  rarer  and 
more  serious  diseases  of  the  bovine  race  have  been  thoroughly 
handled  by  most  of  the  State  boards,  so  that  at  present  there  is 
little  danger  from  pleuropneumonia  or  from  anthrax.  A  good 
deal  of  attention  is  now  given  by  the  State  to  tuberculosis  in 
cattle,  and  by  the  employment  of  tuberculin  as  a  diagnostic 
agent  in  skilled  hands  this  disease  may  be  so  reduced  that  the 
danger  of  harm  resulting  from  it  is  at  a  minimum.  In  cities  of 
considerable  size  a  standard  of  milk  quality  as  to  solid  contents 
is  demanded  of  dairymen,  from  12  to  13  per  cent,  of  solids 
being  required  to  constitute  a  legal  milk,  while  in  some  cities  the 
percentage  of  fat  is  also  defined,  the  requirements  being  not  less 
than  3  per  cent.  Precise  scientific  public  control  of  the  milk 
products  is  as  yet  unknown,  and  only  the  grosser  forms  of  con- 
tamination and  adulteration  are  at  present  regulated  by  law.  It 
is  left  to  the  consumer  to  decide  whether  or  not  a  milk  is  too 
old,  too  sour,  or  too  dirty  to  be  employed.  The  sources  of 
contamination  of  milk  are  many  and  varied  in  number,  and  it 
may  be  said  that  a  larger  number  of  bacteria  to  the  cubic  centi- 
meter can  be  found  in  milk  sold  in  the  poor  districts  of  many 
of  our  cities  than  can  be  found  in  the  sewerage  of  the  same  city. 
A  fresh  milk  often  contains  20,000  bacteria  to  the  cubic  centi- 
meter, and  in  an  old  specimen  that  has  been  exposed,  from 
2,000,000  to  100,000,000  to  the  cubic  centimeter  maybe  found. 
This  contamination  arises  not  only  from  bacteria,  which  may  be 
considered  natural  to  milk  and  which  may  be  comparatively 
harmless  to  adults,  but  also  from  bacteria  which  ought  to  be 
foreign  to  milk  but  are  not.  These  more  poisonous  forms  of 
micro-organisms  are  generally  hurtful  to  both  adults  and  chil- 
dren, while  it  is  safe  to  say  that  all  bacteria  in  milk  are  harmful, 
if  not  indeed  dangerous,  to  infants.  Milk  should  be  kept  free 
from  the  fecal  discharges  of  the  cow,  as  it  is  always  impossible 
to  say  what  varieties  of  bacteria  may  be  present  at  any  given 
time  in  cow  manure,  and  it  is  certain  that  at  times  very  dangerous 
species  are  passed  by  the  animal.  The  pathogenic  bacteria, 
those  of  such  diseases  as  anthrax,  pleuropneumonia,  tuberculosis, 
sepsis  of  the  udder,  diphtheria,  and  other  specific  diseases  of  the 
cow,  may  be  carried  in  milk  to  man  ;  and  the  bacteria  of  a  num- 
ber of  the  diseases  peculiar  to  man,  such  as  typhoid  fever  and 
cholera  infantum,  may,  through  the  carelessness  of  the  milkers, 
be  carried  from  man  to  man  by  the  vessels  in  which  the  milk  is 
kept  or  by  the  milk  itself. 


STERILIZATION    AND    PASTEURIZATION.  123 

Certified  Milk. — A  movement  originating  in  a  committee  of 
the  County  Medical  Society  of  Newark,  N.  J.,  under  the  chairman- 
ship of  Dr.  Coit,  of  Newark,  has  resulted  in  the  production  of  a 
very  superior  milk,  known  as  certified  milk.  The  dairies  sup- 
plying the  milk  are  subjected  to  a  strict  supervision,  and,  in 
the  main,  careful  work  has  been  done  during  the  past  four 
years.  Every  thirty  days  a  committee  of  physicians  visits  these 
farms  and  certifies  to  the  general  condition  of  the  dairies.  Cer- 
tificates from  a  veterinary  surgeon  in  good  standing,  from  one  of 
the  most  eminent  chemists,  and  from  a  well-known  pathologist 
are  obtained  and  distributed  to  all  the  physicians  in  the  district. 
This  milk  has  already  found  its  way  into  over  500  families,  and 
the  demand  exceeds  the  supply.  This  would  be  the  case  in 
many  other  localities,  if  only  the  enterprise  was  understood  and 
appreciated. 

STERILIZATION   AND    PASTEURIZATION. 

Various  methods  have  been  employed  to  maintain  the  nutritive 
properties  of  milk  and  at  the  same  time  destroy  pathogenic  bac- 
teria. For  this  purpose  heat  has  most  generally  been  used  : 
either  raising  the  temperature  of  the  milk  above  the  boiling-point 
and  maintaining  it  there  for  from  twenty  to  thirty  minutes,  or 
quickly  raising  it  to  near  boiling  for  from  eight  to  ten  minutes. 
The  former  is  known  as  sterilization  of  milk  and  the  latter  as 
Pasteurization. 

Sterilization. — As  the  milk  comes  from  the  cow  it  is  a  sterile 
fluid,  but  this  condition  of  purity  can  only  be  maintained  for  a 
very  short  time,  and  for  practical  purposes  the  milk  as  delivered 
to  our  houses  has  passed  through  so  many  hands  and  has  come 
in  contact  with  so  many  vessels  of  at  least  doubtful  cleanliness 
that  some  method  of  reducing  the  number  of  bacteria  to  at  least 
the  minimum  must  be  arrived  at  by  artificial  means.  In  order 
to  attain  this  result  it  was  at  one  time  the  custom  to  raise  the 
temperature  of  the  milk  by  repeated  heating  to  a  point  above 
the  boiling-point  of  water.  By  this  means  all  bacteria  and 
their  spores  were  destroyed,  but  the  results  obtained,  as  far  as 
the  nutrition  of  the  child  was  concerned,  were  bad,  largely  by 
reason  of  the  coagulation  of  the  casein  and  the  destruction  of 
its  nutritious  principles.  The  fat-globules  were  also  made  to 
separate  from  the  emulsion  and  run  together. 

Sterilized  milk  had,  in  some  cases,  a  beneficial  effect  in  the 
prevention  of  gastro-intestinal  disease,  but  the  failure  of  its 
nutritive  qualities  and  its  tendency  to  produce  scurvy  in  young 


124     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

children  have  caused  us  to  seek  some  alternative  which  will 
destroy  pathogenic  bacteria  and  at  the  same  time  preserve  the 
nutritive  qualities  of  the  milk. 

Several  implements  have  been  devised  for  the  sterilization  of 
milk,  probably  one  of  the  best  having  been  invented  by  Starr. 
This  apparatus  consists  of  an  oblong  tin  case  provided  with  a 
neatly  fitting  cover  and  having  a  movable  false  bottom  which 
is  perforated  and  which  stands  a  short  distance  above  the  fixed 
bottom.  To  the  perforated  false  bottom  is  attached  a  frame- 
work capable  of  holding  ten  six-ounce  nursing-bottles.  On  the 
outside  of  the  case  is  a  row  of  supports  for  holding  the  bottles 
while  drying.  A  movable  water-bath  is  hung  at  the  side,  this 
being  for  the  purpose  of  warming  the  food  at  the  time  of  admin- 
istration. It  is  intended  that  ten  nursing-bottles  should  be 
used,  so  that  the  entire  day's  supply  of  milk  can  be  prepared  at 
once.  Each  bottle  is  provided  with  a  perforated  rubber  cork, 
which  is  in  turn  closed  by  a  well -fitting  glass  stopper. 

The  day's  supply  of  milk  should  be  sterilized  in  the  morning 
immediately  after  it  has  been  served  by  the  milkman.  The  direc- 
tions for  the  process  are  as  follows : 

The  bottles  should  first  be  washed  with  hot  water,  soap,  and 
soda,  and  afterward  rinsed  in  clean  boiled  water,  and,  after 
being  thoroughly  dried,  they  should  be  sterilized  in  the  apparatus. 
Every  bottle  is  to  be  filled  with  six  fluidounces  of  milk,  after 
which  the  perforated  rubber  corks  should  be  inserted,  but  with- 
out the  glass  stopper.  In  place  of  both  stopper  and  cork,  a 
piece  of  absorbent  cotton  sufficient  to  close  the  mouth  of  the 
bottle  may  be  used,  as  bacteria  will  not  pass  through  this  sub- 
stance. The  false  bottom  can  now  be  removed  and  the  filled 
bottles  placed  in  the  frame.  The  case  should  now  be  filled 
with  water  to  the  height  of  about  two  inches,  and  the  false 
bottom  containing  the  bottles  replaced.  The  lid  may  now  be 
adjusted  and  the  sterilizer  placed  on  the  kitchen  range.  A  few 
minutes  after  the  milk  has  become  thoroughly  heated  the  glass 
stoppers  are  to  be  placed  in  the  perforated  corks.  The  water 
should  be  allowed  to  boil  around  the  milk  for  twenty  minutes, 
and  at  the  end  of  this  time  the  false  bottom,  with  the  bottles 
contained  thereon,  should  be  removed  and  the  water  poured  off. 
The  milk  is  now  ready  for  use. 

Other  very  efficient  sterilizers  are  those  devised  by  Arnold  and 
Freeman.  Milk  prepared  by  the  foregoing  process  will  remain 
free  from  bacteria  for  several  days. 

A  very  useful  sterilizing  apparatus  is  one  devised  by  Dr.  Ro- 
land G.  Freeman,  of  New  York.  In  the  construction  of  this  the 


STERILIZATION    AND    PASTEURIZATION.  I  25 

inventor  aims  to  do  away  with  the  differences  in  temperature  that 
always  occur  between  the  milk  at  the  bottom  of  the  bottle  and 
that  at  the  top.  The  apparatus  consists  of  two  parts — a  pail  for 
the  water  and  a  receptacle  for  the  bottles  of  milk.  The  pail  is  of 
tin  and  has  a  cover.  A  groove  extends  around  the  body  of  the 
pail  to  indicate  the  level  to  which  it  is  to  be  filled  with  water,  and 
there  are  supports  inside  for  the  receptacle  which  contains  the 
bottles  of  milk  to  rest  on.  This  receptacle  is  made  of  a  series 
of  zinc  tubes  fastened  together,  and  this  fits  into  the  pail,  so  that 
the  lower  inch  of  the  cylinders  is  immersed  in  water.  The  bottles 
of  milk  are  placed  in  these  cylinders.  The  receptacle  has  two 
sets  of  horizontal  supports  :  the  upper  set,  continuing  around  it, 
for  use  while  the  milk  is  being  heated,  and  a  lower  set,  to  be 
used  for  raising  the  milk  while  it  is  cooling.  The  tubes  of  the 
receptacle  are  long  enough  to  each  contain  one  bottle  holding 
from  six  to  eight  ounces.  When  the  receptacle  is  elevated  so 
that  only  the  lower  portion  is  in  contact  with  the  hot  water,  the 
inventor  claims  that  the  temperature  of  the  milk  is  equalized 
throughout  the  whole  bottle. 

Pasteurization. — By  this  process  the  milk  is  kept  for  a  period 
of  from  ten  to  twenty  minutes  at  a  temperature  of  from  160° 
to  170°  F.  (71.1°  to  76.7°  C).  While  this  process  will  not 
destroy  all  the  bacteria  present,  yet  such  pathogenic  organisms 
as  the  spores  of  tuberculosis,  pneumonia,  typhoid  fever,  etc.,  will 
be  destroyed,  and  developed  bacteria  rendered  inert. 

Pasteurization  may  be  accomplished  by  the  use  of  any  of  the 
sterilizers  before  mentioned.  As  special  appliances  for  this  pur- 
pose are  rather  costly  and  somewhat  complex,  a  much  simpler 
one,  known  as  the  Woodbury  sterilizer,  has  been  devised.  This 
consists  of  a  light  wire  frame  made  somewhat  in  the  shape  of  an 
old-fashioned  dinner-caster  and  containing  six  bottles.  These 
bottles  are  graduated  in  ounces  and  have  a  screw  top  like  a  pre- 
serving jar.  In  the  center  of  the  screw-top  lid  is  a  small  opening 
covered  by  a  cap,  through  which  the  steam  escapes. 

To  use  the  apparatus  the  bottle  should  be  filled  with  milk,  and, 
after  being  placed  in  the  wire  frame,  the  whole  apparatus  is  set  in 
a  vessel  of  boiling  water,  care  being  taken  that  the  water  in  the 
vessel  comes  just  about  as  high  as  the  milk  inside  the  jar.  During 
the  first  part  of  the  sterilization  the  small  caps  are  left  off  so  as 
to  allow  the  steam  to  escape. 

The  advantages  of  this  apparatus  are  its  cheapness  and  sim- 
plicity ;  the  disadvantage  lies  in  the  fact  that  the  child  can  not 
nurse  directly  from  the  bottles  because  they  are  not  of  the  proper 
shape  and  size,  but  the  milk  must  be  poured  into  a  nursing-bottle, 


126  FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 

thereby  exposing  it  to  contamination  by  the  air.  Besides  this, 
the  screw  thread  which  is  cut  in  the  glass  for  the  top  to  fit  over 
offers  a  favorable  lurking-place  for  septic  material. 

In  families  in  which,  for  any  reason,  a  sterilizing  apparatus  can 
not  be  obtained,  the  milk  can  be  Pasteurized  in  the  following  simple 
way  :  A  perfectly  clean  preserving  jar  or  clean  bottle  containing 
the  day's  supply  of  milk  mixture  should  be  placed  in  a  kettle  of 
warm  water.  The  water  in  the  kettle  should  be  raised  to  the  boil- 
ing-point. A  clean  all-glass  thermometer  can  be  used  for  testing 
the  temperature  of  the  milk  in  the  jar ;  this  should  be  kept  at 
1 70°  F.  for  from  fifteen  to  twenty  minutes.  The  jar  should  then  be 
removed,  tightly  corked  or  stoppered,  and  placed  on  ice.  During 
Pasteurization  it  is  preferable  that  absorbent  cotton  be  placed  in 
the  neck  of  the  bottle  ;  this  will  allow  the  steam  to  escape,  and 
at  the  same  time  will  prevent  the  entrance  of  bacteria.  In  some 
cases  we  have  found  it  preferable  to  make  up  the  milk  mixture 
for  one  nursing  at  a  time,  and  to  Pasteurize  it  just  before  giving 
it  to  the  child. 

The  shape  and  cleanliness  of  the  nipple  should  receive  careful 
attention.  Probably  the  most  satisfactory  style  of  nipple  is  the 
one  that  has  stood  the  test  of  years  of  use — namely,,  a  nipple 
made  of  plain  rubber  and  conic  in  shape.  Another  form  has 
been  devised,  with  a  small  perforated  protrusion  jutting  off  from 
the  narrow  constricted  portion,  the  object  of  this  being  to  allow 
air  to  pass  in,  so  as  to  prevent  the  nipple  from  collapsing  while 
the  child  is  nursing.  The  nursing  apparatus  consisting  of  a  per- 
forated cork  and  rubber  tube  with  a  nipple  on  the  end  of  it  should 
never  be  used,  as  it  is  impossible  to  keep  it  clean  no  matter  how 
carefully  one  may  try.  Such  a  nipple  after  a  few  days'  use  will 
be  found  swarming  with  bacteria  along  the  entire  inside  of  the 
apparatus. 

After  each  nursing  the  nipple  should  be  carefully  scalded  and 
washed  in  a  strong  solution  of  soda  or  borax,  and  kept  soaking 
in  a  solution  of  boric  acid  and  wrater. 


MODIFIED  MILK. 

The  object  to  be  accomplished  in  modifying  cow's  milk  or  the 
milk  of  other  animals  is  to  change  the  proportions  of  the  milk 
elements — fat,  proteids,  sugar,  and  salts — in  such  a  manner  as  to 
make  a  food  which  will  not  only  resemble  human  milk  in  the 
amount  and  relation  of  the  milk  elements,  but  will  be  per- 
fectly assimilated  by  the  infant.  As  cow's  milk  is  so  much  more 
easily  obtained  than  the  milk  of  other  animals  and  is  in  such 


MODIFIED    MILK.  I2/ 

general  use  for  infant  feeding,  it  will  be  understood  that  in 
treating  the  subject  of  modified  milk  we  mean  modified  cow's 
milk. 

The  reasons  for  changing  the  proportion  of  milk  elements  in 
cow's  milk  before  it  can  be  best  adapted  to  the  digestion  of  the 
human  infant  have  been  explained  in  full  in  a  previous  chapter, 
but,  to  repeat  slightly,  the  amount  of  proteids  is  considerably 
greater  in  cow's  than  in  human  milk,  while  the  proportion  of  fat 
and  carbohydrates  is  about  the  same  or  somewhat  smaller  ;  con- 
sequently, if  we  dilute  cow's  milk  with  water  in  order  to  reduce 
the  proportion  of  proteids  to  that  of  human  milk,  we  reduce  the 
other  elements — fat  and  carbohydrates — far  below  what  we 
require.  Therefore  fat  must  be  added  in  the  form  of  cream  and 
carbohydrates  in  the  form  of  sugar — usually  sugar  of  milk — 
until  the  required  proportion  is  reached. 

It  is  generally  considered,  at  the  present  time,  that  cow's  milk 
so  modified  is  the  best  artificial  food  for  infants,  its  advantages 
being  that  it  is  easily  obtainable,  quite  cheap,  and  capable  of 
almost  unlimited  modification,  thereby  insuring  a  food  which 
can  be  made  to  suit  the  digestion  of  any  child. 

When  the  home  method  is  used,  the  feeding  of  a  child  on 
modified  milk  requires  very  little  more  labor  on  the  mother's 
part  than  does  the  preparation  of  patent  foods.  When  the  in- 
fant is  fed  from  a  milk  laboratory,  the  mother  or  nurse  is  put  to 
absolutely  no  inconvenience  except  to  warm  the  milk  mixture 
before  feeding  it  to  the  infant.  Feeding  a  child  on  modified  milk, 
whether  from  the  laboratory  or  at  home,  requires,  on  the  part 
of  the  physician,  a  careful  study  of  the  physiology  of  infantile 
digestion  in  general,  and  a  close  watch  over  the  individual  case  in 
hand.  Very  few  general  rules  can  be  made  ;  every  infant  should  be 
a  law  unto  itself.  From  the  giving  of  the  first  milk  formula  the 
infant  must  be  constantly  watched,  weighed  at  regular  intervals,  its 
digestive  functions  studied,  and  when  the  slightest  abnormality 
occurs  in  the  stools,  these  should  be  examined  to  see  wherein 
the  food  is  at  fault.  If  vomiting  occur,  a  similar  examination  of 
the  vomited  matter  must  be  made.  When  any  element  of  the 
milk  mixture  is  at  fault,  it  should  be  changed,  until  a  mixture  is 
made  which  perfectly  agrees  with  the  child.  Frequently  the 
changing  of  one  of  the  elements  by  a  fraction  of  I  per  cent,  will 
make  the  greatest  possible  difference  in  the  digestibility  of  the 
milk  mixture. 

When  a  formula  is  at  last  constructed  which  suits  the  child's 
digestion,  there  is,  at  the  present  time,  no  other  food  except  the 
healthy,  mother's  milk  which  will  assimilate  so  well  and  upon 


128     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

which  an  infant  can  be  fed  for  such  a  length  of  time  and  which 
is  capable  of  so  many  combinations  to  suit  the  requirements  of 
the  child's  advancing  age  as  cow's  milk  suitably  modified. 
Although,  doubtless,  many  children  have  thriven  on  pure  cow's 
milk  and  even  on  patent  foods,  this  is  not  the  rule  with  the 
greatest  number  of  children.  Pure  cow's  milk  is  apt  to  produce 
symptoms  of  proteid  indigestion,  and  the  patent  foods,  composed 
chiefly  of  starch,  dextrin,  or  maltose,  even  when  mixed  with  milk, 
tend  to  produce  rickets  or  scurvy.  They  may  in  some  cases  be 
used  for  a  short  time  with  benefit,  but  their  long  continuance  is 
to  be  discouraged. 

Infants  may  be  fed  on  milk  modified  in  milk  laboratories  or  at 
home,  but  in  either  case  the  physician  should  have  personal 
supervision  over  the  matter  and  the  milk  mixtures  should 
be  ordered  or  changed  by  his  prescription  only.  He  should 
see  his  patient  sufficiently  often  to  watch  its  progress,  and 
should  keep  careful  notes  with  copies  of  all  milk  formulas 
given,  and  the  symptoms  following.  All  changes  in  weight  must 
be  carefully  noticed.  It  is  necessary  that  he  should'  have  a 
sufficient  knowledge  of  the  subject  of  modern  infant  feeding  to 
be  able  to  calculate  the  percentages  of  fat,  proteids;  sugar,  and 
the  degree  of  alkalinity  of  the  milk  formulas  that  he  uses,  and 
to  translate  them  into  the  common  measures  of  drams  and  ounces 
of  cream,  milk,  sugar,  etc.  ;  especially  is  this  the  case  if  the  milk 
is  to  be  modified  at  home. 

Milk  Laboratories. — Of  late  years  reliable  milk  laboratories 
have  been  established  in  several  of  the  principal  cities  of  the 
country.  In  1891  Mr.  G.  E.  Gordon  established  in  Boston  what 
was  known  as  the  Walker-Gordon  Milk  Laboratory.  Since  then 
branches  of  this  house  have  been  opened  in  New  York,  Phila- 
delphia, Baltimore,  Montreal,  and  Chicago.  These  laboratories 
furnish  milk  which  is  modified  upon  a  physician's  prescription,  in 
exactly  the  same  manner  as  an  apothecary  dispenses  drugs. 
Briefly  speaking,  the  principal  points  of  superiority  claimed  for 
this  method  are  as  follows  :  i.  The  primal  milk-supply  is  under 
the  supervision  of  the  laboratories,  and  the  cows  are  selected, 
cared  for,  and  fed  with  but  a  single  purpose  in  view — namely,  the 
production  of  a  milk  suitable  for  infant's  use.  2.  The  freshness 
of  the  milk  is  not  impaired  by  the  process  of  preparation.  3. 
In  these  laboratories  milk  is  modified  exactly  and  scientifically. 
Every  infant  has  its  own  milk  freshly  prepared,  the  formula  being 
made  to  suit  its  particular  digestion,  the  fats,  sugars,  and  proteids 
being  prescribed  with  this  object  in  view.  4.  The  milk  is  modi- 
fied and  sold  only  upon  a  physician's  prescription,  so  that  over- 


MODIFIED    MILK. 


I29 


anxious  mothers  and  nurses  can  make  no  mistakes  as  to  the 
quantity  and  quality  of  the  milk  preparation. 

The  greatest  advantages  in  this  method  are  the  accuracy  of 
the  composition  of  the  food  and  its  careful  sterilization  or 
Pasteurization  before  its  delivery.  The  principal  disadvantages 
are  that  it  is  somewhat  expensive  and,  at  the  present  time,  such 
milk  is  hard  to  obtain  within  more  than  a  hundred  miles  from  any 
of  our  large  cities. 

In  compounding  modified  milk  the  directors  of  the  labora- 
tories consider  the  milk  only  in  the  light  of  its  component  parts. 
In  modifying  milk  the  following  articles  are  used:  (i)  Cream 
which  contains  16  per  cent,  of  fat;  (2)  separated  milk  from  which 
the  fat  has  been  removed  by  a  centrifugal  machine ;  (3)  a  stand- 
ard solution  of  sugar  of  milk  of  a  strength  of  20  per  cent.  It 
is  possible,  by  varying  these  elements  in  different  proportions,  to 
produce  almost  any  degree  of  modification.  In  writing  a  pre- 
scription for  a  modified  milk  the  physician  fills  out  a  regular  pre- 
scription form,  furnished  by  the  laboratory,  using  any  percentages 
of  fat,  sugar,  and  proteids  and  the  percentage  of  alkalinity  that 
may  be  desired,  giving  the  quantity  for  each  feeding  and  the 
number  of  feedings  in  the  twenty-four  hours.  The  laboratory 
furnishes  a  daily  supply  in  the  bottles  from  which  the  child  is  to 
be  fed. 


SPECIMEN  MILK  PRESCRIPTION  OF  THE  WALKER-GORDON 
LABORATORY. 


Per  cent. 

Fat 4 

Milk-sugar, 7 

Proteids, 1.5 

Mineral  matter. 
Lime-water. 


Reaction, Slightly  alkaline 

Number  of  feedings,     ...  7 

Amount  at  each  feeding,     .  135  c.c.   (4^  oz.) 

Heated  for, Twenty  minutes 

Heattd  at, 167°  F.  (75°  C.). 


Special  directions. 
For  whom  ordered. 

Date. 


Remarks. 

Infant's  age, Four  months 

Infant's  weight,    ....  14  pounds. 

Signature, 


M.D. 


When  it  is  necessary  to  wean  the  child  or  partially  to  substi- 
tute cow's  milk  in  place  of  breast  milk,  an  analysis  of  the  latter 
should  first  be  made.  If  the  mother's  milk  agreed  with  the  in- 
fant before  it  was  weaned,  a  modified  milk,  the  proportions  of 
which  are  similar  to  the  mother's  milk,  should  be  ordered  by 
the  physician  from  the  laboratory.  Quite  frequently,  however, 
9 


130 


FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 


it  will  be  necessary  to  start  the  infant  on  a  modification  in  which 
the  proportions  of  proteids  and  fats  are  somewhat  lower  than 
they  were  in  the  mother's  milk  previous  to  weaning,  the  reason 
for  this  being  that  the  proteid  of  cow's  milk  is  more  difficult  for 
the  infant  to  digest  than  is  the  same  element  in  human  milk. 
The  amount  of  milk  to  be  given  at  each  feeding  will  depend  in 
a  great  measure  on  the  weight  of  the  child  and  its  gastric  capac- 
ity as  represented  by  its  age. 

The  following  table  will  show  the  total  quantity  of  food  and 
the  relative  proportions  of  fat,  sugar,  and  proteid  which  a 
healthy  infant  can  take  from  birth  until  the  eighteenth  month  : 


AGE. 

FAT. 

SUGAR. 

PROTEIDS. 

DAILY 

QUANTITY. 

First  and  second  day,  

Per  cent. 

Per  cent, 
c 

Per  cent. 

Ounces. 
4-8 

Grams. 
I2S-2SO 

Third  to  seventh  'day,  

2 

6 

0.6 

IO-IS 

•310—460 

Two  to  four  weeks,  

2.  <; 

6 

0.8 

2O—  T.O 

62O-Q7O 

One  to  three  months,    

7 

6 

I 

22-36 

68o-l  HO 

Three  to  four  months    .    . 

rs 

6 

I.2C 

28-38 

870-1  1  80 

Four  to  six  months,  

4 

6 

l.< 

72-^8 

QQO-I  I  80 

Six  to  nine  months,  

4 

7 

2 

72-4.2 

1050—1300 

Nine  to  twelve  months,    .... 
Twelve  to  fifteen  months,    .    . 
Fifteen  to  eighteen  months,     .    , 
Eighteen  months,      

4 
4 
4 

9.* 

6 
5 
5 

A.  -I 

2.5 

3 
3-5 

A 

38-45, 
40-50 

45-50 

4.C-CO 

1180-1400 
1240-1550 
1400-1550 
14.00—  i  i;so 

weight 


Ssnitkin's  investigations  show  that  y^-  of  the  initial 
plus  one  gram  for  each  day  of  life  should  be  taken  as  the  figure 
with  which  to  begin  the  calculation  of  the  relative  weight  of  a 
child  to  its  gastric  capacity. 

Illustration  of  Ssnitkin's  rule  to  aid  in  adjusting  the  food  to 
especially  difficult  cases  in  the  first  thirty  days  : 


INITIAL  WEIGHT. 

AMOUNT  AT  EACH  FEEDING. 

Early  Days. 

At  Fifteen  Days. 

At  Thirty  Days. 

3000  grams,     .    . 
4500  grams,    .    . 
6000  grams,    .    . 

30  grams  (about  I 
oz.  ). 
45    grams    (about 

I/2OZ.). 

60  grams  (about  2 
oz.  ). 

30  +  15  =  45  grams 
(about  \y2  oz.  ). 
45  -1-  15  —  60  grams 
(about  2  oz.). 
60  +  15  =  75  grams 
(about  zy2  oz.). 

30  +  30  =  60  grams 
(about  2  oz.  ). 
45  +  3°  =  75  grams 
(about  2.yz  oz.). 
60  -f-  30  =  90  grams 
(about  3  oz.). 

When  the  child's  digestion  is  weak,  the  proportions  of  the  vari- 
ous constituents  of  the  milk,  especially  the  fats  and  proteids, 
may  have  to  be  changed  several  times  before  a  modification  can 


MODIFIED    MILK.  13! 

be  made  which  will  be  suitable  for  permanent  use.  As  the  child's 
digestive  apparatus  becomes  stronger  the  proportions  of  proteids 
and  fats  may  be  gradually  increased  until  the  following  propor- 
tions are  obtained  : 

Fat, 3  per  cent. 

Sugar, 6       " 

Proteids, I        " 

The  preparation  should  be  made  slightly  alkaline  and  heated 
to  a  temperature  of  167°  F.  (75°  C.).  This  formula  will  repre- 
sent about  the  average  constitution  of  human  milk  with  a  rather 
low  percentage  of  proteids.  If  the  infant  seems  to  thrive  on 
this  and  continues  gradually  to  gain  in  weight,  the  proportion 
of  fats  and  proteids  may  be  slowly  raised  until,  by  the  time  it 
has  reached  the  tenth  or  eleventh  month  of  life,  it  is  taking  pure 
cow's  milk.  This  should  have  enough  lime-water  added  to  make 
rit  somewhat  alkaline  in  reaction,  and  should  be  heated  to  about 
167°  F.  (75°  C.).  The  weight  of  the  infant  and  the  state  of  its 
digestion  are  points  which  must  guide  us  as  to  whether  any 
particular  modification  is  doing  well.  There  are  certain  general 
symptoms  in  the  infant  which  will  guide  our  knowledge  as  to 
whether  or  not  the  milk  is  doing  all  that  is  required  of  it.  When 
the  percentage  of  fat  is  too  high,  the  child  will  have  frequent  re- 
gurgitations  of  food  in  small  quantities,  these  usually  appearing 
an  hour  or  two  after  feeding.  The  bowel  movements  are  fre- 
quent and  sometimes  of  normal  appearance,  but  in  some  cases 
they  may  contain  small  round  lumps  resembling  casein,  but 
which  are  really  composed  of  fat.  Not  infrequently,  also,  the 
child  will  give  evidence  of  suffering  from  colic. 

When  the  child  is  receiving  too  small  an  amount  of  fat,  the 
bowels  are  constipated  and  the  stools  dry  and  hard.  When  the 
amount  of  siigar  is  in  excess,  there  will  be  frequent  eructations 
of  gas  from  the  stomach  and  regurgitation  of  small  quantities 
of  milk.  Colic  will  also  be  present,  and  the  stools  are  apt  to  be 
green,  thin,  and  very  acid,  often  causing  severe  irritation  of  the 
buttocks.  In  cases  where  the  percentage  of  sugar  is  too  low,  the 
gain  in  weight  is  slow  or  absolute  loss  of  flesh  may  be  noticed. 
When  the  proportion  of  proteids  is  too  high,  the  infant  cries  a 
great  deal  because  of  colic,  and  constipation  is  the  rule,  although 
occasionally  there  may  be  short  attacks  of  diarrhea,  the  stools 
containing  masses  of  curd.  Vomiting  is  frequent,  the  vomited 
matter  containing  curds  of  varying  size.  Imperfect  digestion  of 
proteids  may  cause  much  the  same  symptoms  as  when  this  ele- 
ment is  in  excess,  as,  indeed,  it  really  is  too  great  in  proportion 


132  FEEDING   AND    FOOD    OF    INFANTS    AND    CHILDREN. 

to  the  digestive  capacity.  A  general  excess  of  food  may  produce 
very  much  the  same  symptoms  as  when  the  individual  elements 
are  in  excess.  Holt  has  summarized  the  indications  for  modifi- 
cation of  the  various  constituents  of  milk  as  follows  : 

If  the  child  is  not  gaining  in  weight  without  special  signs  of 
indigestion,  increase  the  proportions  of  all  the  ingredients.  If 
habitual  colic  is  present,  diminish  the  proteids.  If  vomiting  ap- 
pear very  soon  after  feeding,  reduce  the  quantity  of  food  given. 
For  the  regurgitation  of  sour  masses  of  food  reduce  the  fat  and 
sometimes  the  proteids.  For  obstinate  constipation  increase 
both  fats  and  proteids. 

Home  Modification. — The  question  of  the  modification  of 
milk  at  home  is  one  of  much  importance  and  interest.  By  even 
a  slight  study  of  this  subject  the  practitioner  will  often  be  able 
to  restore  to  health  many  infants  who  do  not  need  drugs  to  help 
them,  and  who  are  not  sick,  but  starving.  It  is  not  necessary 
that  a  child  should  be  without  food  to  starve  ;  many  children 
perish  every  year  while  being  given  plenty  of  nourishment,  as  far 
as  quantity  goes,  the  composition  of  the  food  being  such  that  it 
is  either  not  digested  at  all  or  only  partially  digested,  the  most 
of  it  remaining  in  the  stomach  and  intestines  subject  to.  fermenta- 
tion and  later  setting  up  acute  or  subacute  forms  of  fermentative 
diarrhea.  At  first  sight  the  method  for  the  scientific  modifica- 
tion of  milk  such  as  has  been  placed  before  the  profession  by 
the  careful  labors  of  Rotch  and  others  is,  so  far  as  the  technic 
goes,  a  rather  difficult  one,  and  yet  a  little  study  of  the  subject 
will  show  it  to  be  not  so  perplexing  as  at  first  sight ;  even  the 
busiest  of  practitioners  can,  in  a  short  time,  obtain  a  knowledge 
of  infant  feeding  which  will  enable  him  to  instruct  the  mother  as 
to  the  needs  of  the  patient,  and  to  make  a  food  much  better 
because  nearer  in  composition  to  the  child's  natural  diet  than 
any  of  the  proprietary  foods  so  commonly  used. 

There  are  several  methods  by  which  milk  can  be  modified  at 
home,  none  of  them  being  very  complex.  We  give,  however, 
only  those  which  are  the  simplest  and  best  adapted  for  ordinary 
use: 

Holfs  Metlwd. — This  plan  of  modification,  which  is  somewhat 
more  complicated  than  one  which  will  be  given  later,  is  as  fol- 
lows : 

It  is  essential  to  have  on  hand  the  elements  from  which  the 
desired  formulas  can  be  compounded.  First,  for  the  fat  it  is 
necessary  to  have  one  of  the  following  preparations  of  cream  : 
(l)  a  12  per  cent,  cream — i.  e.,  one  that  contains  12  per  cent,  of 
fat.  This  may  be  obtained  by  using  equal  parts  of  the  ordinary 


MODIFIED    MILK.  133 

20  per  cent,  centrifugal  cream  and  plain  milk  ;  or  (2)  by  using 
two  parts  of  ordinary  skimmed  or  gravity  cream  (such  as  would 
be  produced  by  allowing  milk  to  set  overnight)  containing  16 
per  cent,  of  fat  mixed  with  one  part  of  plain  milk.  Second,  an 
8  per  cent,  cream.  This  may  be  obtained  by  using  (i)  one  part 
of  20  per  cent,  centrifugal  cream  and  three  parts  of  plain  milk  ; 
or  (2)  by  using  one  part  of  gravity  cream  and  two  parts  of  plain 
milk;  or  (3)  using  the  top  layer  from  milk  which  has  been  stand- 
ing for  five  or  six  hours. 

The  following  solutions  of  sugar :  A  5  per  cent,  solution, 
made  by  dissolving  I  ounce  of  milk-sugar  in  20  ounces  of 
water,  or  one  even  tablespoonful  in  7^  ounces  of  water  (one 
even  tablespoonful  represents  three  drams).  A  6  per  cent,  solu- 
tion: one  ounce  of  milk-sugar  is  dissolved  in  16^  ounces  of 
water,  or  one  even  tablespoonful  in  6^  ounces  of  water.  A  7 
per  cent,  sugar  solution  :  one  ounce  of  sugar  is  dissolved  in  14 
ounces  of  water,  or  one  even  tablespoonful  in  5  y2  ounces  of 
water.  An  8  per  cent,  sugar  solution :  one  ounce  is  dissolved 
in  12^/2  ounces  of  water,  or  one  even  tablespoonful  in  4^  ounces 
of  water.  A  10  per  cent,  sugar  solution  :  twice  the  strength  of 
a  5  per  cent,  solution. 

Other  Articles  Needed. — Some  freshly  prepared  lime-water, 
some  filtered  water  which  has  been  boiled  for  fifteen  minutes, 
several  nursing-bottles,  preferably  of  cylindric  shape  and  gradu- 
ated to  ounces  and  drams,  plain  rubber  nipples,  and  some  ab- 
sorbent cotton.  The  method  of  preparing  'the  milk  is  as  fol- 
lows :  (i)  To  decide  the  proportion  of  each  of  the  elements  to 
be  used  ;  (2)  the  number  of  feedings  in  the  twenty-four  hours  ; 
(3)  the  quantity  for  each  feeding.  Suppose  we  wish  the  formula 
to  contain  3  per  cent,  of  fat,  6  per  cent,  of  sugar,  and  I  per 
cent,  of  proteids,  and  we  require  nine  feedings  of  four  ounces 
each  :  it  is  necessary  to  prepare  thirty-six  ounces  of  food.  In 
order  to  make  up  this  formula  the  following  proportions  of  the 
various  elements  are  necessary  : 

Centrifugal  cream,  .    4^  ounces  1            f  Skimmed  cream,     .    .    6  ounces 

Plain  milk,  ....    4^  "      /  (       \  Plain  milk,       .        .    .    3       " 

Milk-sugar,     ...    2  "  or       $)4  even  tablespoonfuls 

Boiled  water,  .    .      25^  "      \          /  Boiling  water,     ...  27        " 

Lime-water,     .    .    .     \l/2  "       j  (       \Bicarbonateof  soda,  .  36  grains. 

The  sugar  is  to  be  dissolved  in  boiling  water  and  filtered 
through  cotton  and  allowed  to  cool  partially.  The  milk  and  cream 
should  next  be  added  and  the  whole  mixed  in  a  pitcher,  after 
which  the  alkaline  liquid  (either  lime-water  or  a  solution  of  bi- 
carbonate of  soda)  or  plain  sterilized  water  is  to  be  added.  The 


134     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

mixture  is  now  to  be  divided  into  nine  bottles,  the  mouths  of 
which  should  be  stoppered  with  cotton.  The  bottles  should 
next  be  placed  in  a  sterilizer  for  Pasteurization  or  sterilization, 
according  to  directions.  Otherwise  they  should  be  cooled  by 
standing  in  cold  water  for  fifteen  minutes,  during  which  time  the 
temperature  of  the  water  is  to  be  reduced  by  the  addition  of 
ice.  The  food  should  be  kept  in  an  ice-chest  until  time  for  use, 
when  it  should  be  heated  slightly  by  placing  in  warm  water. 
The  principal  fault  to  be  found  with  this  method  is  the  variety 
of  proportion  in  the  ingredients  used.  To  be  able  to  combine 
these  in  definite  ratio  so  as  to  make  an  accurately  compounded 
milk  formula  requires  no  little  study  and  calculation. 

Rotctts  Method. — Rotch  has  devised  a  much  simpler  method 
for  the  modification  of  milk  at  home.  The  articles  required  are 
the  following :  A  wide-mouthed  glass  jar  holding  one  quart,  a 
siphon  of  glass  tubing,  /^  to  ^  of  an  inch  in  diameter,  and 
bent  so  that  the  end  from  which  the  milk  is  to  flow  is  six  inches 
longer  than  that  which  is  inserted  in  the  jar. 

One  quart  of  fresh  milk  from  a  herd  of  cows  is  thoroughly 
strained  and  put  into  the  jar,  which  is  kept  open  for  fifteen 
minutes  in  order  to  allow  it  to  cool.  The  jar  is  then  sealed 
tightly,  and  placed  in  a  vessel  containing  iced  water  and  salt,  in 
the  proportion  of  a  teaspoonful  of  salt  to  a  quart  of  water.  This 
is  set  in  a  cool  place  for  six  hours.  At  the  end  of  this  period 
siphon  out  three-fourths  of  the  milk  from  the  bottom  of  the  jar 
into  a  clean  vessel.  The  mouth  must  not  be  used  to  start  the  flow 
of  the  milk  through  the  siphon,  but  the  latter  must  be  filled  with 
clean  boiled  water,  the  longer  end  closed  with  the  finger  and  the 
siphon  inverted,  the  shorter  end  being  placed  in  the  milk.  When 
the  finger  is  withdrawn,  the  water  followed  by  the  milk  will  run 
out  of  the  longer  division. 

The  materials  necessary  for  preparing  the  milk  mixture  are  the 
following  : 

1.  The  milk  which  has  been  siphoned  from  the  jar. 

2.  The  cream  which  remains  in  the  jar  and  which  contains  10 
per  cent,  of  fat. 

3.  Milk-sugar.     This  may  be  purchased  by  the  pound  and 
divided  by  the  druggist   into   packages,   each   containing   3^$ 
drams  (200  grains),  or  a  measure  containing  3  ^  drams  may  be 
made. 

4.  Some  lime-water. 

5.  Some  well-boiled  and  filtered  drinking-water. 

The  milk-sugar  is  first  to  be  dissolved  in  the  water  and  the 
other  ingredients  then  added. 


MODIFIED    MILK.  135 

The  following  tables  are  prepared  by  these  rules  : 

i.  Low  PERCENTAGE  OF  FAT  AND  PROTEIDS. 

Proteids, 0.25  Cream ^  ounce 

Fat, 0.25  Milk, I          " 

Sugar,    .        4  Lime-water,      .    .    .    .     I          " 

Lime-water,      ....  5  Water, 17^  ounces 


20  ounces 

Milk-sugar,  .....     2  measures  (or 
6      drams. 


2.  Low  PERCENTAGE  OF  FATS  AND  PROTEIDS. 

Proteids,    ......  0.75  Cream,  .......     2 

Fat,    ........  I    "  Milk,      ...    .....    2 

Sugar,    .......  5  Lime-water,      .    .    .    .     i 

Lime-water,      ....  5  Water,  .......  15 


20  ounces 
Milk-sugar,  ....         2  measures. 


3.  FOR  WEANING. 

Proteids, 3.5  Cream, 

Fat, 4  Milk, 

Sugar, 4.5 


4.  FOR  WEANING. 

Proteids, 3-2S  Cream, 8      ounces 

Fat, 4  Milk, 8 

Sugar, 5  Lime-water,      ....  I      ounce 

Lime-water 5  Water, 3      ounces 


20  ounces 
Milk-sugar, J/%  measure. 


5.  FOR  WEANING. 

Proteids, 3  Cream, 8      ounces 

Fat, 4  Milk, 7^       " 

Sugar, 5  Lime-water,      .    .    .    .  I       ounce 

Lime-water,      ....  5  Water, 3^  ounces 

20  ounces 

Milk-sugar, I  measure. 


6. 

Proteids, 3  Cream,  .......  8      ounces 

Fat, 4  Milk, 7^      " 

Sugar, 7  Lime-water,      .    .    .    .  i      ounce 

Lime-water,      ....  5  Water, 3^  ounces 

20  ounces 

Milk-sugar, 2  measures. 


136 


FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 


Proteids,    . 
Fat,    .    .    . 
Sugar,    .    .    , 
Lime-water, 


I 

2 

5-5 

5 


Proteids, I 

Fat, 2.5 

Sugar, 6 

Lime-water, 5 


Proteids, 1.5 

Fat, 3-5 

Sugar, 6.5 

Lime-water, 5 


Proteids, 1.5 

Fat, 4 

Sugar, 7 

Lime-water, 5 


Cream, 4       ounces 

Milk, l}4       " 

Lime-water,      .    .    .    .     I       ounce 
Water, 13'^  ounces 


20  ounces 


Milk-sugar, 


Cream, 5      ounces 

Milk, None 

Lime-water,     .    .    .    .     i      ounce 
Water, 14      ounces 


20      ounces 
Milk-sugar,     ....    2^  measures. 

Cream, 7  ounces 

Milk, I  ounce 

Lime-water,     .    .    .    .  I  " 

Water, n  ounces 


20     ounces 
Milk-sugar,     ....    2>4  measures. 

Cream, 8    ,  ounces 

Milk, None 

Lime-water,     .    .    .    .     I      ounce 
Water, 11      ounces 


20      ounces 
Milk-sugar,     ....    2^  measures. 


Proteids, 2 

Fat 4 

Sugar, 7 

Lime-water, 5 


Proteids, 2.5 

Fat, 4 

Sugar, 7 

Lime-water, 5 


Cream, 8     ounces 

Milk, 2^      " 

Lime-water,    ....  I      ounce 

Water, 8>£  ounces 

20     ounces 

Milk-sugar,     ....  2)4  measures. 

Cream, 8     ounces 

Milk, 5 

Lime-water,    .    .    .    .  I      ounce 

Water, 6     ounces 


Milk-sugar, 


ounces 
measures. 


In  some  cases  barley-water  may  be  used  with  advantage  in 
place  of  lime-water  or  in  combination  with  it.  The  special  indi- 
cations for  this  will  be  mentioned  later  on. 

Of  late  much  attention  has  been  paid  by  those  especially  in- 
terested in  infant  feeding  by  modified  milk  to  the  simplification 
of  the  methods  of  calculating  the  percentages  of  the  elements 


MODIFIED    MILK.  137 

which  constitute  a  milk  mixture.  Until  recently  the  methods 
used  in  the  calculation  of  these  formulas  were  of  so  complex  a 
nature  and  involved  so  large  an  amount  of  work  that  the  average 
practitioner  had  not  the  time  nor  patience  to  give  the  subject  the 
attention  it  deserved.  The  matter  is  also  made  more  complex 
because  of  the  difficulty  in  getting  a  milk  or  cream  of  a  standard 
quality  on  which  to  base  our  calculations.  However,  as  the 
study  of  the  subject  continues  and  our  knowledge  increases, 
simpler  methods  will  doubtless  be  invented.  Out  of'the  many 
methods  used  at  the  present  time,  we  have  endeavored  to  describe 
only  those  which  have  stood  the  test  of  practical  experience. 

Westcott:  's  method  of  calculating  the  proportions  of  cream, 
milk,  and  milk-sugar  in  percentage  mixtures  is  probably  the 
most  accurate  method  which  has  been  devised  ;  it  is  capable  of 
wide  application.*  In  the  calculation  the  following  symbols 
are  used  : 

C  —  Cream  in  ounces. 

M  =  Milk  in  ounces. 

Q  =  Total  quantity  of  mixture  in  ounces. 

F  =  Desired  fat  percentage. 

P  =  Desired  proteid  percentage. 

S  =  Desired  sugar  percentage. 

L  =  Ounces  of  dry  sugar  of  milk  to  be  added. 

In  his  calculations  he  uses  practically  the  Walker-Gordon 
analyses,  which  are  the  same  as  those  given  by  Holt  and  Rotch 
and  are  here  copied  from  Westcott  : 

M,  .....        -4  per  cent,  fat,  4  per  cent,  proteids,         4.4  per  cent,  sugar. 

C  (12  per  cent.),    .  12         "         "          3.8        "  "  4.2         "  " 

C(i6  per  cent),    .16         "         "          3.6        "  "  4  "  " 

The  quantities  of  cream,  milk,  and  dry  milk-sugar  required  to 
make  any  desired  quantity  of  a  mixture  containing  chosen  per- 
centages of  fat,  proteid,  and  sugar  can  be  rapidly  calculated  by 
substituting  these  known  values  in  the  following  formulas  and 
working  out  the  indicated  mathematical  processes  to  find  values 
for  C,  M,  and  L  : 

For  a  combination  of  12  per  cent,  cream  and  4  per  cent. 
(whole)  milk  the  formulas  are  : 

Q  (F-P) 
"  8~ 


QS  -  4-30  (C  -4-  M) 


*See    "International    Clinics,"    Oct.,   1900.     "The   Scientific    Modification    of 
Milk,"  by  Dr.  Thompson  S.  Westcott. 


138  FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 

For  a  combination  of  16  per  cent,  cream  and  4  per  cent. 
(whole)  milk  the  formulas  are  : 

r  _  Q  (F-P) 

\^t   -  - 

12.4 
M=^-4C 

_QS  —  4-20  (C  +  M) 

J_i  —  —  —  —  -      -  . 

no 

If  20  per  cent,  cream  is  used,  the  denominator  of  the  fraction 
giving  the  value  of  C  should  be  16.8,  and  5  instead  of  4  should 
be  used  as  coefficient  of  C  in  the  equation  for  M. 

In  the  sugar  formulas  4.3  and  4.2  represent  the  mean  between 
4.4  and  4.2,  and  between  4.4  and  4,  respectively,  the  sugar  per- 
centages of  the  cream  and  milk  in  each  case,  the  mean  value 
being  used  for  the  sake  of  simplicity. 

There  are  a  few  exceptions  to  the  formulas  previously  given 
which,  as  quoted  from  Westcott,  are  as  follows  :  "In  proteid 
percentages  less  than  I,  16,  or  even  32  per  cent,  cream  may  be 
required  for  the  higher  fat  values  ;  in  proteid  values  from  i  to 
1.25,  1  6  per  cent,  cream  is  required  for  fat  values  from  3.25  to 
4  for  the  lower,  and  from  3.75  to  4.00  for  the  highen,  of  these 
proteid  percentages.  Also  for  the  higher  proteids  (2.25  to  4) 
skimmed  milk  instead  of  cream  would  be  required  for  fat  per- 
centages lower  than  the  proteid  percentage.  In  practice,  how- 
ever, it  is  extremely  rare  to  use  a  fat  percentage  lower  than  the 
proteid,  so  that  this  method  will  be  found  to  give  very  satisfac- 
tory working  results." 

After  the  amounts  of  cream,  milk,  and  sugar  have  been  calcu- 
lated and  measured,  the  quantity  should  be  made  up  with  boiled 
drinking-water,  barley-water,  or  other  suitable  diluent. 

Example.  —  Required  a  forty-ounce  mixture  containing  : 

Result. 
Fat,    ........  3     per  cent.       Cream,  ......    7.3    fluidounces 

Sugar,    .......  5          "  Milk,     ......    8.1  " 

Proteids,    ......  1.5       "  Lime-water,      ...    2  " 

Lime-water,      ....  5          "  Water,  ......  22.6  " 

Sugar  of  milk,      .    .     1.34  ounces. 

C  (12  per  cent.)  =  40(3-1.50)   =  f-  =  7.3  fluidounces. 

o.2  O.2 

M      .....  ==  —     —  —  3  X  7-3  =  30  —  21.9  =  8.1  fluidounces. 

4 


Lime-water  .   .  =  40  X  0.05   =  2  fluidounces. 

Water  .    .    .    .  =  40  —  (7.3  +  8.1  +  2)  =  22.6  fluidounces. 

T  40  X  5  —  4-3  (7-3  +  8.1)         200  —  66.22 

L  ......  =  -  -  =  '-34  ounces. 


MODIFIED    MILK.  139 

Baner  ("New  York  Medical  Journal,"  March  12,  1898)  rec- 
ommends a  series  of  practical  rules  for  calculating  the  amount 
of  each  milk  element.  These  rules  are  based  on  the  under- 
standing that  good  cow's  milk  contains  an  average  of  4  per  cent. 
fat  and  4  per  cent,  proteids.  Cream  is  regarded  as  a  superfatted 
milk  containing  practically  the  same  amount  of  proteids  as  milk 
itself.  So  long  as  the  cream  is  fresh  and  clean,  we  may  use 
either  a  12  per  cent,  cream,  obtained  by  allowing  milk  to  stand 
over  in  a  tall  vessel  for  six  hours  and  removing  the  upper  fifth  ; 
a  1  6  per  cent,  cream,  obtained  by  skimming,  or  a  20  per  cent. 
cream,  obtained  by  the  use  of  a  separator.  For  convenience  in 
explanation  the  16  per  cent,  gravity  cream  is  employed  in  the 
following  rules,  but  only  a  slight  change  is  necessary  if  cream 
of  another  percentage  is  used.  Having  decided  on  the  exact 
percentage  deemed  most  suitable  for  the  case  and  the  number 
of  ounces  required  for  the  day's  feeding,  the  physician  will 
proceed  to  estimate  the  amount  of  cream  to  be  used  in  the  mix- 
ture according  to  the  following  rule  : 

Subtract  the  proteid  percentage  from  the  fat  percentage  and 
multiply  the  remainder  by  the  total  number  of  ounces  in  the 
mixture  divided  by  12.  This  gives  the  total  number  of  ounces 
of  cream.  To  estimate  the  quantity  of  milk  needed,  multiply  the 
quantity  of  the  mixture  by  the  proteid  percentage  and  divide  by 
4.  This  gives  the  total  quantity  of  milk  and  cream.  Subtract 
from  this  the  amount  of  cream,  and  the  remainder  will  be  the 
amount  of  milk  required.  It  is  hardly  necessary  to  estimate  the 
water,  as  it  is  self-evident  that  the  entire  mixture  less  the  milk 
and  cream  will  be  water.  To  obtain  the  amount  of  dry  milk- 
sugar,  multiply  the  difference  between  the  sugar  and  proteid  per- 
centages by  the  quantity  of  the  mixture  and  divide  by  100. 
Baner's  formulas  for  determining  the  amounts  of  cream,  milk, 
water,  and  dry  milk-sugar  required  to  make  any  desired  quantity 
or  mixture  to  contain  given  percentages  are  as  follows  : 

Given  : 

Quantity  desired  (in  ounces)    .  .  .  =  Q 

Desired  percentage  of  fat      .    .  .  .  =  F 

Desired  percentage  of  sugar     .  .  .  =  S 

Desired  percentage  of  proteids  .  .  =  P 

To  find  (in  ounces)  : 

Cream  (16  per  cent.)  =  ~  X  (F  —  P) 


Milk  ,«.  _c 

4 
Water    ......  =  Q  —  (C  +  M) 

/g  _  p\  x  Q 
Dry  milk-sugar      .    .  =  —  -  —  . 


I4O  FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 

If  20  per  cent,  centrifugal  cream  is  used,  the  denominator  of 
the  cream  formula  will  be  16  instead  of  12.  If  12  per  cent, 
cream  is  used,  it  will  be  8  instead  of  12. 

Examples. — Suppose  a  forty-ounce  mixture  is  required  con- 
taining fat  4  per  cent.,  sugar  7  per  cent.,  and  proteids  2  per  cent.  : 


Cream 

Milk 

Water 

Sugar 


=  --  X  2  = 


ounces 


—          —  6%  ounces  = 
40  —  20  =  20  ounces 
5  X  4°  . 


=  2  ounces. 


To  find  the  quantities  of  each  element  in  a  twenty-four  ounce 
mixture  containing  fat  4  per  cent.,  sugar 
6  per  cent,  and  proteids  15  per  cent.  : 


Cream  .    .   = 


Milk 
Water 


—  X  2-5  =  5  ounces 
24  X  1.5 


—  5  =  4  ounces 


Milk-sugar  = 


=  24  —  9  =  15  ounces 

4-5  X  24 


=  1.8  ounces. 


The  usefulness  of  this  method  depends 
upon  the  ease  with  which  odd  amounts 
of  a  mixture  can  be  calculated  ;  on  the 
other  hand,  it  must  be  remembered  that 
a  very  high  percentage  of  fat  with  a 
low  proteid  percentage  can  not  be  made 
from  a  12,  16,  or  even  a  20  per  cent, 
cream. 

Other  practical  methods  for  the  home 
modification  of  milk  have  been  suggested 
by  Morse,*  Townsend.f  and  others.  The 
methods  of  Morse  and  Townsend  are  very  similar,  but  Townsend's 
is  perhaps  the  simpler.  It  is  based  on  the  use  of  the  top  quarter 
of  milk  that  has  stood  for  six  hours,  the  percentages  being :  fat, 
10  per  cent. ;  proteid,  4  per  cent.  ;  sugar,  4  per  cent.  The  rule 
to  be  remembered  is  as  follows  :  Each  ounce  of  10  per  cent, 
cream  in  a  twenty-ounce  mixture  represents  0.5  per  cent,  of  fat, 
0.2  per  cent,  of  proteids,  and  0.2  per  cent,  of  sugar,  and  each 
even  tablespoonful  of  sugar  of  milk  represents  2  per  cent.  In  a 
mixture  containing  4  per  cent,  of  fat  the  highest  proteid  obtain- 


FIG.  18. — ESTRAN'S  MATEKNA. 


*  "Annals  of  Gyn.  and  Pediatrics,"  April,  1899. 
f  "  Boston  Med.  and  Surg.  Jour.,"  March  23,  1899. 


MODIFIED    MILK. 


141 


able  is  1.6  per  cent.  ;  the  proteid  may  then  be  raised  by  taking 
more  of  the  milk  than  the  top  quarter,  or  by  adding  whole  milk, 
which  contains  fat,  or  the  bottom  quarter,  which  is  nearly  free 
from  fat. 

One  of  the  easiest  methods  of  modifying  milk  at  home  is  by 
the  use  of  the  Materna.  This  is  a  large  graduated  glass  beaker 
having  on  its  outer  surface  seven  panels,  one  graduated  in  ounces 
and  the  other  six  graduated  in  the  following  manner  : 


1 

3D  TO  I4TH 

DAY. 
Fat,          2     # 
Proteids,  0.6  $ 
Sugar,      6     <f 

2 

2D  TO  6TH 

WEEK. 
Fats,         2.5  tf 
Proteids,  0.8  <i 
Sugar,      6     '% 

3 

6TH  TO  IITH 
WEEK. 
Fats,         3  <f, 
Proteids,  i  <p> 
Sugar,       6  <j> 

4 

IITH  WEEK  TO 
STH  MONTH. 

Fats,        3.5  $ 
Proteids,  1.5  <£ 
Sugar,      7    £ 

5 

5TH  TO  9TH 

MONTH. 
Fats,         4  % 
Proteids,  2  $ 

Sugar,      7  <f, 

6 

9TH  TO  I2TH 

MONTH. 
Fats,        3.5  # 
Proteids,  2.5$ 
Sugar,      3.5  £ 

Milk. 

Milk. 

Milk. 

Milk. 

Milk. 

Milk. 

Cream. 

Cream. 

Lime-water. 

Cream. 

Lime-water. 

Water. 

Lime-water. 

Water. 

Lime-water. 

. 

Water. 

Water. 

Water. 

Cream. 

Barley  Gruel. 

* 

Milk-sugar. 

Milk-sugar. 

Milk-sugar. 

Milk-sugar. 

Milk-sugar. 

Grape-sugar. 

Gaertner,  in  his  "  Fettmilch"  or  mother's  milk,  aims  to  reduce 
the  excess  of  casein  in  cow's  milk  by  the  use  of  the  following 
method  :  A  separator,  known  as  the  Pfanhauser  centrifuge,  making 
4800  revolutions  a  minute  is  employed.  The  machine  is  filled  with 
equal  parts  of  fresh  cow's  milk  and  sterilized  water.  The  speed 
of  the  centrifuge  is  regulated  so  as  to  separate  the  mixture  into  (.1) 
creamy  fatty  milk  and  (2)  skimmed  milk.  The  two  portions  are 
led  off  by  as  many  openings.  An  analysis  of  each  of  these  por- 
tions shows  that  the  creamy  milk  has  the  same  quantity  of  fat  as 
is  found  in  human  milk.  About  2  per  cent,  of  the  casein  is  con- 
tained in  the  skimmed  milk,  and  the  balance,  1.7  per  cent,  re- 
mains in  the  creamy  milk.  In  order  to  bring  up  the  proportion 
of  sugar  to  that  found  in  human  milk,  about  three  or  four  grams 
of  milk-sugar  are  added  to  every  100  c.c.  of  the  fat  milk.  It  is 
claimed  that  the  fat  milk  has  the  advantage  over  diluted  milk  of 


142     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

having  a  higher  percentage  of  fat,  while  the  curd  is  rendered 
more  digestible.  When  the  digestion  is  very  weak,  it  is  some- 
times necessary  to  predigest  the  milk,  wholly  or  partially,  before 
the  child's  stomach  will  retain  it.  Escherich  has  laid  down  the 
following  rules  for  the  amount  and  frequency  with  which  this 
food  may  be  given  :  During  each  twenty-four  hours  children  two 
weeks  old  require  16  ounces  in  nine  meals  ;  from  two  to  four 
weeks  old,  25  ounces  in  eight  meals  ;  from  four  to  eight  weeks 
old,  33  ounces  in  eight  meals.  Children  from  three  to  four 
months  old  require  42  ounces  in  eight  meals ;  from  five  to  six 
months  old,  50  ounces  in  seven  meals. 

Backhand  Kindermilch. — The  results  of  this  method  of  infant 
feeding  have  been  reported  by  Kolisko  and  others.  The  milk  is 
taken  from  a  selected  herd,  strict  cleanliness  being  observed,  and 
the  cream  separated  by  centrifugation.  The  skimmed  milk  is  then 
mixed  with  rennet,  trypsin,  and  sodium  carbonate,  and  kept  at  a 
temperature  of  40°  C.  (104°  F.)  for  half  an  hour,  the  trypsin 
having  by  this  time  converted  30  per  cent,  of  the  casein  into  a 
soluble  form  of  albumin,  the  remainder  being  precipitated  by  the 
rennet.  Steam  is  then  introduced,  and  the  temperature  raised  to 
80°  C.  (176°  F.)  for  five  minutes.  The  mixture  is  then  strained 
through  cloths,  after  which  one-half  the  volume  of  water,  one- 
fourth  the  volume  of  cream,  and  the  necessary  amount  of  milk- 
sugar  are  added.  It  is  then  divided  into  bottles  containing  125 
c.c.  (4  ounces),  and  sterilized  and  sealed.  The  Kindermilch  is 
made  in  three  strengths,  as  follows : 

i.         n.        m. 

Fat 3-i  3-2  3-3 

Milk-sugar, 6  5.4  4.8 

Casein, 0.6  1.8  3 

Albumin,     .    .  I  0.3  0.5 

Salts, 0.4  0.4  0.7 

Various  other  methods,  such  as  the  addition  of  albumose  or 
egg-albumen,  have  also  been  recommended. 

Predigestion. — Several  methods  of  doing  this  have  been  re- 
sorted to.  Probably  the  most  successful  consists  in  the  use  of 
an  amount  of  extract  of  pancreatin  relatively  small  in  proportion 
to  the  amount  of  milk.  This  is  used  simply  to  start  the  process 
of  predigestion,  the  process  being  then  arrested  by  quickly  rais- 
ing the  temperature  of  the  milk  to  a  degree  sufficient  to  destroy 
the  ferment.  By  this  method  the  milk  shows  less  readiness  to 
"curdle  by  the  addition  of  rennet  or  an  acid,  and  the  curd  thrown 
down  is  in  smaller  particles  and  softer  than  that  found  in  fresh 
cow's  milk.  It  should  be  borne  in  mind  in  feeding  a  child  on 


DIET    OF    CHILDREN    DURING    FIRST    EIGHTEEN    MONTHS.       143 

predigested  food  that  while  this  form  of  nourishment  acts  very 
well  for  a  short  time  in  children  with  weak  digestion,  yet  a  long- 
continued  course  of  such  foods  will  predispose  the  patient  to 
rickets  or  scurvy,  particularly  if  the  milk  has  been  subjected  to 
the  longer  method  of  sterilization. 


DIET  OF  CHILDREN  FROM  THE  SIXTH  TO  THE 
EIGHTEENTH  MONTH. 

During  the  first  year  of  life  the  infant's  food  should  be  milk, 
preferably  milk  from  the  mother's  breast,  or  that  failing,  the  best 
substitute  is  cow's  milk  modified  in  the  manner  described.  If 
the  latter  method  has  been  used,  it  will  be  found  that  as  the  child 
advances  in  age  and  its  digestive  capacity  increases,  the  total 
quantity  of  the  milk  mixture  must  be  increased  from  time  to 
time  ;  this  is,  however,  not  all  that  will  be  necessary.  In  the 
healthy  infant  the  power  to  digest  the  proteids  of  milk  increases 
rapidly  with  its  age,  and  consequently  this  constituent  must  be 
increased  in  quantity  in  the  milk  formula  prescribed.  By  the 
sixth  month  the  following  formula  may  be  given  : 

Percentage.  By  Measure. 

Fat, 4  per  cent.  Cream, 8     ounces 

Sugar, 7       "  Milk, 2^     " 

Proteids, 2       "  Lime-water,     ....         I      ounce 

Lime-water,    ....  5       "  Water, 8^  ounces 


20      ounces 
Sugar  of  milk,    ....     2^  measures. 

The  proportion  of  proteids  has  here  been  increased,  while  the 
fat  and  sugar  are  relatively  less.  The  proteids  may  thus  be  in- 
creased from  time  to  time  until  the  tenth  or  twelfth  month,  at 
which  time  the  child  ought  to  be  able  to  take  whole  milk, 
properly  Pasteurized  and  made  alkaline  by  lime-water,  bicarbon- 
ate of  soda,  or  table  salt.  If  the  child  has  been  fed  on  breast 
milk  up  to  the  tenth  or  twelfth  month,  it  may  be  gradually 
weaned  in  the  manner  previously  described.  An  analysis  of  the 
mother's  milk  may  now  be  made  and  a  corresponding  milk  mix- 
ture used  until  the  child  becomes  accustomed  to  an  artificial 
diet,  but  the  ultimate  object  should  now  be  to  prepare  the  diges- 
tion for  foods  containing  other  substances  than  are  found  in  milk, 
although  the  latter  must  still  for  a  considerable  period  be  the 
principal  article  of  diet. 

By  the  eleventh  or  twelfth  month  the  capacity  to  digest  starch 
is  fully  developed.  After  this  period  of  life,  sugar,  as  such,  is 


144     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

not  the  only  heat-producing  food  ;  in  fact,  it  becomes  secondary 
in  importance  to  starch  in  this  capacity.  It  must  not  be 
supposed  that  the  power  of  digesting  sugar  is  any  feebler,  but  as 
starchy  foods  can  be  taken  and  assimilated,  the  need  for  sugar  is 
not  so  great.  Following  this  principle  we  can  with  propriety 
introduce  into  the  child's  diet  toward  the  end  of  the  first  year  of 
life  various  foods  containing  starch,  and  it  is  best  that  we  use  for 
the  purpose  articles  which  contain  this  principle  in  its  simplest 
form.  The  following  may  be  advantageously  used  : 

Oat  or  Barley  Jelly  (the  former  contains  slightly  more  starch 
than  the  latter,  while  both  contain  a  certain  per  cent,  of  fat). — 
Oat  jelly  can  be  made  in  the  following  manner :  Four  ounces 
(120  gm.)  of  coarse  oatmeal  are  allowed  to  soak  in  a  quart  of 
cold  water  for  twelve  hours.  The  mixture  is  then  boiled  down 
so  as  to  make  a  pint.  It  is  then,  while  hot,  strained  through  a 
fine  cloth.  Barley  jelly  is  made  in  practically  the  same  manner. 

The  intervals  between  feedings  will  vary  somewhat  with  the 
age  of  the  child.  An  average  of  three  hours'  interval  will  do 
very  well  until  the  child  is  eight  or  nine  months  old,  when  the 
number  of  feedings  may  be  decreased  and  the  quantity  at  each 
feeding  increased.  The  lengthened  interval  is  quite  necessary  after 
the  introduction  of  a  proprietary  food  or  a  food  containing  starch. 

From  the  end  of  the  first  year  of  life  a  child  should  receive 
about  five  meals  a  day,  the  first  to  be  given  at  about  7  A.M.,  and 
should  consist  of  eight  ounces  of  modified  milk  made  in  the 
following  proportions  : 

Percentage.  By  Measure. 

Fat, 4  per  cent.  Milk,         6  ounces 

Sugar, 5         "  Cream, I  ounce 

Proteids,    .....  3        "  Water, 3  ounces 

Sugar  of   milk,  two  even  tea- 
spoonfuls. 

This  may  be  varied  by  the  use  of  barley  or  oatmeal  jelly  in  the 
same  proportion  as  the  water.  At  the  second  meal  much  the 
same  quantity  of  milk  may  be  given,  or  at  this  feeding  one  or 
two  tablespoon fu Is  of  one  of  the  standard  proprietary  foods  or 
"  flour  ball  "  may  be  used. 

Flour  ball  is  made  as  follows  :  A  pint  of  wheat  flour  of  good 
quality,  without  bran,  is  tied  tightly  in  a  pudding  bag.  This  is 
placed  in  a  saucepan  of  water  and  boiled  constantly  for  ten 
hours.  It  is  then  allowed  to  cool,  the  bag  removed,  and  the 
outer  covering  of  dough  cut  away.  The  yellowish-white  interior 
of  the  mass  consists  almost  entirely  of  dextrin,  which  has  been 
formed  from  the  starch  during  the  process  of  cooking.  This 


DIET    OF    CHILDREN    DURING    FIRST    EIGHTEEN    MONTHS.       145 

interior  is  reduced  to  a  powder  by  grating.  To  prepare  for  use 
in  a  nursing-bottle,  rub  a  teaspoonful  of  the  powder  with  a  table- 
spoonful  of  milk  until  a  smooth  paste  is  formed  ;  a  second  table- 
spoonful  of  milk  is  now  added,  with  constant  rubbing.  This 
quantity  should  be  poured  into  eight  ounces  of  hot  milk,  the 
milk  being  continuously  stirred  while  the  paste  is  poured  in. 

By  the  fifteenth  month  the  child,  providing  it  is  still  on  a  diet 
of  modified  milk,  may  be  given  a  formula  such  as  the  following  : 

Percentage.  By  Measure. 

Fat, 4      per  cent.  Milk, 8      ounces 

Sugar, 5  "  Cream ^  ounce 

Proteids, 3.5       "  Water, 1^  ounces 

Sugar    of  milk,    one    even   tea- 
spoonful. 

Occasionally  the  diet  may  be  varied  by  giving  the  child  at  one  of 
the  feedings  a  small  quantity  of  whey.  This  is  prepared  as 
follows  :  A  pint  of  milk  is  warmed,  and  two  teaspoonfuls  of  Fair- 
child's  essence  of  pepsin  are  added.  The  mixture  is  then 
allowed  to  stand  until  the  process  of  coagulation  of  the  curd  is 
completed.  It  is  then  beaten  with  a  fork  until  the  curd  is  finely 
subdivided,  after  which  it  is  strained. 

Sometimes  a  small  quantity  of  animal  food  may  be  introduced 
into  the  child's  diet  with  benefit  ;  this  is  particularly  the  case 
when  an  attack  of  indigestion  supervenes.  Beef-extract  or  thin 
beef  or  mutton  broth  can  be  used  for  this  purpose. 

Beef-juice  is  prepared  in  the  following  manner :  A  pound  of 
beef  sirloin  should  be  warmed  in  a  broiler  before  a  quick  fire  ;  it 
should  then  be  cut  into  small  pieces  and  placed  in  a  lemon- 
squeezer  or  meat-press,  so  as  to  express  the  juice,  which  is 
caught  in  a  hot  cup.  All  fat  should  be  removed.  Care  should 
be  taken  not  to  cook  the  meat. 

Beef  Broth. — One  pound  of  lean  beef  should  be  minced  finely 
and  put  with  its  juice  into  an  earthen  vessel  containing  a  pint  of 
water  at  85°  F.  (29.4°  C).  It  should  then  be  allowed  to  stand 
for  one  hour,  after  which  it  is  strained,  preferably  through  stout 
muslin,  until  all  the  juice  is  removed  from  the  meat.  The  liquid 
is  then  placed  on  the  fire  and  heated  slowly  just  to  the  boiling- 
point,  being  stirred  all  the  time  ;  it  is  then  removed  and  seasoned 
with  salt. 

Mutton  brotli  is  prepared  by  gently  boiling  one  pound  of  loin 
mutton  in  three  pints  of  water  until  the  meat  is  tender  ;  a  small 
quantity  of  salt  should  then  be  added,  and  the  whole  strained 
into  a  basin  ;  skim  off  the  fat  as  soon  as  cold.  Both  beef  and 
mutton  broths  should  be  warmed  before  giving  them  to  the  child. 


146  FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 

A  child  of  eight  or  nine  months  can  occasionally  be  given  the 
yolk  of  an  egg  lightly  boiled  and  mixed  with  stale  bread-crumbs, 
or  a  small  quantity  of  a  well-roasted  potato  may  be  given  for  one 
meal  a  day  once  or  twice  a  week.  When  broths  are  used,  they 
should  be  given  in  quantities  of  about  four  or  five  ounces,  either 
plain  or  mixed  with  bread-crumbs  or  finely  crumbled  Zwieback. 
Chicken  broth  may  also  be  used  at  this  time  of  life  as  an  occa- 
sional substitute  for  milk,  or  a  good  proprietary  food  which  can 
be  prepared  with  milk. 

Chicken  broth  is  made  in  the  following  manner:  A  small 
chicken,  or  half  of  a  large  one,  after  being  thoroughly  cleaned  and 
having  all  the  fat  and  skin  removed,  is  chopped  into  small  pieces, 
bones  and  all  ;  a  pinch  of  salt  is  added  and  the  whole  is  placed 
in  a  saucepan  containing  a  quart  of  boiling  water.  The  cover 
of  the  saucepan  should  be  closed  tightly  and  the  contents  allowed 
to  simmer  over  a  slow  fire  for  two  hours.  After  removing, 
allow  it  to  stand,  still  covered,  for  an  hour.  The  broth  is  then 
strained  through  a  sieve.  From  three  to  five  ounces  should  be 
given  at  one  feeding.  As  a  general  rule,  broths  should  only  be 
substituted  for  milk  for  about  one  feeding  daily  two  or  three 
times  a  week. 

The  diet  from  the  eighth  until  the  twelfth  month  should  be 
much  the  same,  except  that  the  amounts  of  nitrogenous  and 
starchy  foods  may  be  steadily  increased.  It  should  be  borne  in 
mind  that  every  young  child  needs  an  occasional  change  of  diet. 
Their  entire  digestive  system  should  be  gradually  taught  to  do 
its  duty.  The  juires  of  meats,  and  even  the  meat  itself  finely 
comminuted,  may  occasionally  be  given  in  small  quantities  as 
early  as  the  tenth  or  eleventh  month.  It  is  also  necessary  to 
impress  on  the  mind  of  the  mother  or  nurse  that  the  child  needs 
water  ;  this  should  be  given  in  quantities  of  an  ounce  or  two  at 
a  time ;  it  should  be  sterilized  by  some  means  or  other,  preferably 
by  boiling,  and  the  child  should  be  encouraged  to  drink  several 
times  a  day.  The  best  method  of  securing  pure  water  is  by 
means  of  a  Pasteur  filter  attached  to  one  of  the  faucets  in  the 
kitchen,  but  as  this  appliance  requires  water  under  pressure  such 
as  is  found  in  the  water  system  of  cities  and  is  somewhat  expen- 
sive, it  can  not  be  obtained  at  all  households.  A  very  good  way 
to  sterilize  water  is  to  fill  a  number  of  thoroughly  cleaned  beer- 
bottles  from  a  hydrant  or  spring,  and  after  filling  the  mouth  of 
the  bottle  with  absorbent  cotton,  to  subject  the  water  to  boiling 
temperature  for  about  half  an  hour.  The  cotton  may  then  be 
removed  and  the  bottle  tightly  stoppered  by  means  of  the  gum 
cork  and  wire  attachment  if  the  bottle  is  equipped  with  a  patent 


DIET    OF    CHILDREN    FROM    THE    SECOND    YEAR.  147 

stopper ;  otherwise  cork  tightly.  This  water  may  be  given  to 
the  child  cold,  or  in  the  heat  of  summer  even  with  small  pieces 
of  ice  in  it,  or,  better,  cooled  by  indirect  chilling. 

In  infants  or  young  children  suffering  from  intestinal  disorders 
from  five  to  twenty  drops  of  good  brandy  or  whisky  may  often 
be  added  to  each  drink  of  water  with  advantage.  In  cases  of 
constipation  moderate  drafts  of  oatmeal-water,  and  in  cases  of 
diarrhea  allowing  the  child  to  have  frequent  drinks  of  barley- 
water,  not  only  satisfy  thirst,  but  do  good  in  relieving  these  con- 
ditions and  are  valuable  adjuncts  in  the  treatment.  Both  of 
these  are  better  thirst  quenchers  than  plain  water.  All  the 
mineral  waters  have  their  uses  in  the  therapeutics  of  childhood, 
and  in  fever  cases  the  effervescent  mineral  waters,  particularly 
aerated  Poland,  Apollinaris,  or  simple  soda  or  Vichy  water  in 
siphons,  are  very  refreshing.  These  should  be  given  in  quanti- 
ties of  an  ounce  or  two  at  a  time,  and  may  be  at  times  mixed 
with  a  small  quantity  of  lemon-juice.  Given  with  cracked  ice  and 
with  a  small  quantity  of  brandy  or  whisky  added,  they  are  very 
valuable  in  many  cases  of  severe  vomiting.  In  the  renal  affections 
of  childhood  aerated  waters  are  serviceable  in  keeping  the  kid- 
neys well  flushed  out  and  aiding  the  excretion  of  effete  products. 


DIET  OF  CHILDREN  FROM  THE  SECOND  YEAR. 

At  the  commencement  of  the  second  year  of  life  we  find  the 
child  still  needing  milk  as  a  chief  constituent  of  its  diet.  In 
bottle-fed  babies  the  milk  should  be  modified  so  that  the  albu- 
minoids and  fats  are  considerably  increased.  A  useful  formula 
for  this  age  may  be  prepared  as  follows  : 

Milk 1l/2  fluidounces 

Cream,  l/2  fluidounce 

Milk-sugar, , I  dram 

Salt, ...  a  pinch 

Water, 2  fluidounces. 

The  child  should  now  be  given  more  of  ordinary  table  diet ; 
either  the  white  or  yolk  (the  latter  preferred)  of  a  soft-boiled 
egg  may  be  used  for  one  feeding  a  day.  Broths,  such  as 
chicken,  mutton,  or  beef  broth,  should  also  be  used,  and  a  small 
quantity  of  finely  chopped  or  scraped  underdone  beefsteak  may 
be  given  for  one  or  two  feedings  a  day.  Some  form  of  animal 
food  should  almost  always  be  used  at  least  once  a  day. 

For  one  or  two  meals  each  day  one  of  the  standard 
proprietary  foods  may  be  given.  At  this  age  five  meals  a  day 


148     FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 

can  be  well  borne.  The  first,  preferably  the  foregoing  milk 
formula,  should  be  given  at  about  7  A.M.  ;  the  second,  which  may 
be  omitted  if  the  child  is  not  hungry,  should  be  taken  about  1 1 
A.M.  ;  the  third,  which  should  be  the  heaviest  meal  of  the  day, 
may  contain  the  largest  amount  of  animal  food.  This  should 
be  given  at  about  I  or  2  o'clock  in  the  afternoon  ;  the  fourth 
feeding,  which  may  be  a  repetition  of  the  first  or  consist  of  milk 
mixed  with  one  of  Liebig's  foods,  should  be  taken  at  about  6 
P.M.  Before  retiring  for  the  night  the  child  may  take  a  cup  of 
warm  milk  rendered  slightly  alkaline  by  lime-water  or  salt. 

Toward  the  end  of  the  second  year  a  child  may  receive  four 
meals  a  day.  These  should  consist  of  a  breakfast  composed 
principally  of  milk,  to  which  a  small  quantity  of  thoroughly 
cooked  oatmeal  or  wheaten  grits  or  one  or  two  slices  of  stale 
bread  may  be  added.  A  child  should  never  receive  fresh  or  hot 
bread  in  any  form.  At  about  10.30  or  11  A.M.,  if  the  child  is 
hungry,  it  may  receive  a  tumbler  of  warm  milk.  The  dinner 
should  be  eaten  at  about  I  or  2  o'clock,  and  at  this  meal  the 
child  may  be  given  a  small  piece  of  underdone  roast-beef  or 
chicken  or  turkey — any  of  the  lighter  meats,  in  fact.  This  may 
be  supplemented  by  one  or  two  vegetables,  such  as  a  well- 
roasted  potato  mashed  with  a  fork.  Such  green  vegetables  as 
spinach,  cauliflower,  peas,  or  string-beans  may  occasionally  be 
used  as  alternates  for  potatoes.  At  this  meal,  also,  junket,  plain 
rice-pudding,  good  fresh  fruits,  and  occasionally  ice-cream  may 
be  used  for  desserts.  In  children  with  weak  digestion  a  table- 
spoonful  of  sherry  v  water  given  immediately  after  the  dinner  is 
useful.  Tea  and  coffee  should  be  prohibited,  but  the  child  may 
drink  a  cup  of  milk  or  cocoa  with  good  effect.  Bread,  not  too 
fresh,  may  also  be  eaten  with  the  dinner. 

At  about  7  P.M.  the  child  should  receive  its  last  meal  ;  this 
may  be  composed  of  a  slice  or  two  of  bread  and  butter  or  well- 
made  milk  toast.  About  eight  ounces  of  milk  may  also  be 
taken  at  this  meal.  A  small  quantity  of  some  plainly  stewed 
fruit  with  the  seeds  removed  is  often  given  with  benefit.  Unless 
there  are  some  special  indications  for  it,  it  is  better  not  to  give 
the  child  meat  at  this  meal.  From  this  age  on  the  diet  of 
childhood  gradually  approximates  nearer  and  nearer  to  that  of 
adult  life.  It  should  be  remembered  that  the  heaviest  meal — 
the  dinner — should  be  given  somewhere  near  noon.  The 
breakfast  and  supper  should  consist  largely  of  milk,  although 
other  easily  digested  foods  in  quantities  to  suit  the  child's  age 
are  admissible.  It  is  usually  well  to  give  some  light  food,  such 
as  milk,  between  breakfast  and  dinner  and  dinner  and  supper, 


DIET    OF    CHILDREN    FROM    THE    SECOND    YEAR.  149 

since  the  intervals  between  the  time  of  adults'  meals  are  rather 
too  long  for  the  youthful  digestive  organs  to  run  without  some 
nourishment  being  supplied.  It  is  advisable  to  allow  no  candies 
or  cakes,  and  thus  prevent  the  child  acquiring  a  taste  for  them. 
If  this  is  impossible,  such  things  should  be  permitted  only 
immediately  after  a  meal,  and  better  only  as  a  special  reward  for 
good  conduct. 

o 

Proprietary  Foods. — Many  of  these  foods  seem  to  be  quite 
carefully  prepared,  and,  having  the  advantages  of  convenience 
and  cheapness,  may  be  introduced  with  good  results  by  the  end 
of  the  first  year.  It  has  been  taught  by  some  authorities  that 
finely  divided  starch  or  dextrin  introduced  into  milk  acts  in  two 
different  ways  :  first,  by  its  nutrient  properties,  and,  second,  by 
its  mechanical  action.  By  the  term  mechanical  action  is  meant 
the  diffusion  of  the  particles  of  the  food  among  the  globules  of 
fat  and  the  casein  of  the  milk  in  such  a  manner  as  to  prevent 
the  formation  of  masses  of  curd  in  the  digestive  tract  of  the 
child.  This  theory  has  of  late  years  been  disputed,  and  experi- 
ments seem  to  prove  that  the  action  of  these  substances  as  attenu- 
ants,  so  called,  is  of  little  consequence.  As  far  as  their  nutri- 
tious properties  are  concerned,  the  proprietary  foods  are,  as  a  rule, 
inferior  to  milk,  for  two  reasons  :  First,  the  proportion  of  tissue- 
building  to  the  heat-producing  elements  is  much  below  that  of 
milk.  In  the  second  place  the  starch,  which  is  a  heat-producing 
principle,  must  be  converted  into  sugar  before  it  can  be  absorbed. 
This  change  is  accomplished  by  the  action  of  the  pancreatic 
juice  and  saliva,  neither  of  which  is  to  any  extent  developed 
before  the  fourth  month  of  life.  The  undigested  starch,  there- 
fore, remains  in  the  gastro-intestinal  canal  and  is  extremely 
likely  to  cause  fermentation.  In  order  to  make  up  in  some 
degree  for  their  lack  of  nutritive  properties,  all  farinaceous  foods 
should  be  prepared  with  milk,  and  it  really  becomes  a  question 
whether,  in  infants  under  eight  or  ten  months  of  age,  the  nutri- 
tious principles  are  not  dependent  much  more  on  the  milk  than 
on  the  proprietary  food.  In  regard  to  proprietary  foods,  it  may 
be  said  that  their  best  quality  is  that  they  form  an  easy  and  con- 
venient way  of  introducing  starch  or  partially  dextrinized  starch 
into  some  modification  of  milk. 

Foods  Containing  Starch,  Dextrin,  or  Maltose. — Many  prepara- 
tions are  sold  in  which,  by  previous  heating  or  by  digestion  with 
diastase,  wheat-  or  barley-flour  is  so  modified  as  to  be  more 
easily  digested  than  simple  starch.  By  the  action  of  a  tempera- 
ture of  300°  or  400°  F.  (160°  or  204.4°  C.)  the  principal  sub- 
stance, starch,  forms  dextrin,  a  body  differing  from  starch  in  the 


I5O  FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 

fact  that  it  is  soluble  and  has  the  characteristics  of  a  gum. 
Quoting  from  the  investigations  of  Professor  Leeds,  we  find  that 
the  flour  selected  for  such  treatment  should  be  rich  in  albu- 
minous substances  and  made  from  wheat  grown  at  certain  sea- 
sons and  of  a  certain  grade,  and  should  be  made  by  the  roller 
process. 

Liebig's  Foods. — Under  this  head  may  be  classed  a  number 
of  proprietary  foods  the  essential  construction  of  which  is  as  fol- 
lows :  The  flour  is  prepared  by  means  of  diastase,  equal  parts 
of  wheat  flour  and  barley  malt  being  used,  and  a  certain  amount 
of  wheat  bran  being  added.  The  latter  substance  is  used  because 
of  the  adherent  phosphates  and  nitrogenous  matter.  To  these 
i  per  cent,  of  bicarbonate  of  potassium  is  added,  with  water 
sufficient  to  make  a  thin  paste.  This  mixture  is  allowed  to  stand 
for  several  hours  at  the  ordinary  temperature,  after  which  the 
latter  is  raised  to  1 50°  F.  (65.6°  C),  and  this  is  continued  until  all 
the  starch  is  converted  into  maltose  and  dextrin.  The  mixture 
is  then  strained  and  the  residue  pressed  and  exhausted  with  warm 
water,  after  which  the  extract  is  evaporated  into  vacuum  pans  at  a 
moderate  degree  of  heat.  The  process  is  completed  by  drying 
at  a  higher  temperature,  the  mixture  being  stirred  thoroughly. 
By  reference  to  the  table  the  composition  of  many  of  these  foods 
can  be  seen. 

Proprietary  Foods  Intended  to  be  Used  Without  Milk. — 
This  class  of  proprietary  foods  is  prepared  with  the  intention  of 
using  them  without  the  addition  of  milk,  water  only  being  neces- 
sary to  prepare  them  for  the  feeding.  In  the  majority  of  these 
the  starch,  which  has  been  partially  or  completely  converted  into 
dextrin,  has  been  evaporated  with  milk  during  their  manufacture. 
An  outline  of  their  preparation  is  somewhat  as  follows  :  The 
flour  is  first  made  into  dough  and  baked,  after  which  it  is  finely 
ground  and  mixed  with  condensed  milk,  and  then  dried  by  a  slow 
heat  of  moderate  degree.  In  the  resulting  mixture  the  starch 
has  been  wholly  or  partially  converted  into  maltose,  dextrin,  or 
dextrose.  The  albuminoids  of  the  flour  have  undergone  about 
the  same  changes  as  take  place  in  other  farinaceous  foods.  The 
milk-sugar  has  undergone  coagulation,  and  the  casein  has  be- 
come dried  into  a  fine  powder.  An  example  of  this  class  of 
foods  is  the  one  sold  under  the  name  of  Nestle's  food. 

In  regard  to  the  value  of  these  foods  we  must  say  that  there 
is  no  one  of  them  that  can  be  referred  to  as  being  the  best  upon 
which  to  feed  a  large  number  of  children  or  a  single  child  during 
a  long  period  of  time.  That  they  have  a  certain  amount  of  use- 
fulness can  not  be  doubted. 


PROPRIETARY    FOODS. 


TABLE  OF  THE  CONSTITUENTS  OF  LIQUID  FOODS  AND 
PEPTONOIDS. 

(From  Bulletin  No.  10,  Department  of  Agriculture.) 


CARBOHY- 

DRATES. 

ti 

Z 

NAME  OR  BRAND. 

H 

h 

a 

V 

H 

i 

REMARKS. 

> 

fa 

0 

tt 

3 

.Q 

b 

< 

CM 

3 

"3 

Beef  peptonoids  (dry), 
Bovinine,    

4.91 
62.18 

3-49 
Trace. 

63.18 
15.35 

3-54 
4-3 

Specific  gravity  1.049. 
Contains  alcohol    and 

boric  acid. 

75-8i 

Trace. 

O.I  I 

24-49 
12.91 

2.18 

Specific  gravity  1.020. 

Murdock's  liquid  food, 

contains  alcohol. 

FOODS  FOR  INFANTS  AND  INVALIDS. 


Carnrick's  soluble  food, 

3.12 

6.26 

16.32 

56.62 

14.44 

O.22 

3-02 

Horlick's  food,    .... 

3.64 

2.OI 

11.28 

63.14 

17.28 

0-73 

1.92 

Horlick's  malted  milk, 

2.87 

7.81 

16.61 

59-43 

10-95 

0.52 

1.81 

Hubbell's    prepared 

wheat,     .           .... 

5-93 

I.I9 

14.81 

16.16 

60.86 

0.31 

0-44 

Imperial  granum,   .   .    . 

iQ-57 

1.32 

19-37 

15-42 

51.88 

0.31 

I-I3 

Just's  dietetic  food,  .   . 

4-83 

0.79 

3-85 

70.6 

18.31 

0.51 

i.  ii 

Lactopreparata,         .   . 

3-28 

6.26 

22.48 

58.89 

7.21 

0.81 

1.07 

Liebe's  soluble  food,     . 

22.03 

0.08 

3-32 

76.38 

1.41 

Mellin's  food    .  .       .   . 

3-93 

2.O4 

11.87 

CQ   4C 

17  71 

O  *,"* 

4*47 

2-74 

7.12 

13.37 

Jy-tJ 
6l.I9 

i/.  /i 
I3-63 

UO3 

0.63 

1.32 

Nestle's  food,   

2-37 

4.Q4 

11.04 

43-75 

35-73 

O.47 

1.61 

Nursing  meal,  

10.84 

t-^j 
2.36 

6.22 

44.66 

32.96 

"•<}/ 
0.63 

2.31 

Contains  cocoa. 

Nutrico  food  ,   .   .    . 

11.87 

4-38 

13-4 

9-75 

57-83 

0.61 

1-77 

Ridge's  food,    

8.87 

1.67 

13.37 

8.32 

66.35 

0.81 

0.61 

Wagner's  infant  food,  . 

5-°7 

10.91 

14.81 

37-91 

28.91 

0-37 

2.OI 

Wells,    Richardson    & 

Co.'s  lactated  food,   . 

2-94 

2.67 

13.22 

28.84 

48.45 

1-37 

2.51 

Zimmerman's  health 

food,        

6  79 

1-33 

11.16 

14.73 

63.97 

0.71 

1.31 

Simple  Attenuants. — The  principal  use  of  these  is  to  dilute 
the  milk  and  at  the  same  time  add  somewhat  to  its  nutritious 
property.  Many  of  them  have  a  slight  therapeutic  action  upon 
the  intestinal  tract  of  the  child.  Of  those  in  use,  probably  the 
best  are  barley-water,  gelatin -water,  and  oatmeal -water. 

Barley-water  can  be  made  as  follows  :  Into  a  saucepan  con- 
taining a  pint  of  water  put  two  teaspoonfuls  of  washed  pearl 
barley,  boil  slowly  down  to  two-thirds  of  a  pint,  and  strain. 

Gelatin-water :  Put  a  piece  of  plate  gelatin  an  inch  square  into 
half  a  tumblerful  of  cold  water,  and  let  it  stand  for  three  hours. 
Then  turn  the  whole  into  a  teacup,  place  this  in  a  saucepan  half 
full  of  water,  and  boil  until  the  gelatin  is  dissolved.  One  or  two 
teaspoonfuls  of  this  should  be  added  to  about  four  ounces  of 
water.  When  made  with  milk,  about  the  same  quantity  of  the 
jelly  is  to  be  used  to  each  bottle  containing  eight  ounces. 

Oatmeal-water :   To  a  pint  of  water  add  from   one  to  three 


152 


FEEDING  AND  FOOD  OF  INFANTS  AND  CHILDREN. 


tablespoonfuls  of  well-cooked  oatmeal ;  heat  until  it  has  almost 
reached  the  boiling-point,  and  stir  constantly. 

Lime-iuatcr :  A  piece  of  unslaked  lime  the  size  of  an  English 
walnut  should  be  dropped  into  two  quarts  of  boiled  or  filtered 
water  contained  in  an  earthen  vessel ;  the  water  is  then  stirred 
thoroughly  and  allowed  to  settle.  The  water  should  be  used 
only  from  the  top  and  should  be  replaced  as  consumed. 

Condensed  Milk. — Condensed  milk  is  used  largely,  especially 
by  the  poorer  classes,  as  an  article  of  food  for  infants.  Being 
sealed  in  air-tight  cans  or  jars  and  containing  a  large  quantity  of 
sugar,  it  is  easily  preserved  for  a  considerable  time.  It  is  also 
cheap  and  prepared  with  comparatively  little  trouble — both  quali- 
ties which  will  recommend  it  to  the  poor  mother  with  the  cares 
of  a  large  family.  All  that  is  necessary  for  its  preparation  is  to 
mix  it  with  a  certain  quantity  of  water  and  pour  it  into  a  nursing- 
bottle.  Regarding  the  relative  proportions  of  the  principal  ele- 
ments of  condensed  milk,  Professor  Leeds,  of  Hoboken,  found  in 
the  analysis  of  a  large  number  of  specimens  the  following  pro- 
portions of  its  constituents  : 


MILK  CONDENSED 
WITH  CANE-SUGAR 
ADDED. 
No.  i. 

THE  SAME  DILUTED 
WITH  EIGHT  TIMES 
ITS  WEIGHT  OF 
WATER. 

Fat,      

12.  IO 

1.51 

Albuminoids,      ...                     .... 
Lactose,  

I6.O7 
16.62 

2.OI 

2.08 

Sucrose,  

22.26 

2.78 

Ash  

2.61 

0.32 

Total  solids,    

69.66 

8.70 

Water,     

•?O.  -?4 

QI.7O 

IOO.OO 

IOO.OO 

ANGLO-SWISS  MILK, 
PRESERVED  WITHOUT 
ADDED  SUGAR. 
No.  2. 

AMERICAN-SWISS, 
PRESERVED. 
No.  3. 

Fat,      

13.21 

II.  SH 

Albuminoids,      

II.  96 

H.  IO 

Lactose  ... 

15.20 

13.04 

Sucrose,  

Ash,     

1.78 

2.OQ 

Total  solids,    .        .    . 

41.64 

4O.78 

Water,     

58.36 

5Q.  22 

IOO.OO 

IOO.OO 

DIET    OF    CHILDREN    FROM    THE    SECOND    YEAR. 


153 


Fat,   .... 

Albuminoids, 
Lactose,  .  . 
Sucrose,  .  . 
Ash 


SAME  AS  3,  DILUTED  \VITH 

FIVE  TIMES  ITS  WEIGHT 

OF  WATER. 

.    .    .    .         2.64 

.    .          2.27 

•     •    .    -         3-05 


0.36 

Total  solids, 8.32 

Water, 91.68 


TABLE   SHOWING  THE   CONSTITUENTS  OF  EVAPORATED  CREAMS 
AND  UNSWEETENED  CONDENSED  MILKS.* 


NAME  OF  BRAND. 

WATER. 

Per 
cent. 

FAT. 

Per 
cent. 

PROTEIN. 

Per 
cent. 

MILK- 
SUGAR. 
Per 
cent. 

CANE- 
SUGAR. 
Per 
cent. 

ASH. 

Per 
cent. 

EVAPORATED  CREAMS. 

62.72 

10.68 

Q.23 

13.72 

2.04 

Highland,     .        

68.75 

0.6"? 

Q.  21 

IO.80 

•52 

Howell's,      

71.92 

8.81 

8.53 

8.82 

.82 

Imperial,       .        

69.54 

9.56 

8.61 

10.42 

.87 

Loeflund,      

68.37 

7.81 

10.17 

11.84 

.81 

Monroe,    

69.64 

8.91 

9.54 

10.44 

•47 

Romanshorn,    

66.28 

IO.  3Q 

0.77 

11.47 

2.09 

St.  Charles, 

66.46 

Q.26 

IO.4Q 

12.24 

1.55 

CONDENSED  MILKS. 
Anglo-Swiss,    

21.56 

9.37 

Q.  l6 

13.39 

40.45 

2.07 

Babv,     

22.99 

IO.6l 

9.91 

14.24 

40.17 

2.08 

Dime,    

23.88 

7.34 

10.07 

12.7 

43-95 

1.96 

Full  Weight,    
Gail  Borden's  "  Eagle,"     . 
Good  Luck,  

25.58 
30.16 
27.11 

9.29 

7.51 
8.29 

9-44 
8.4 

Q.O^ 

11.71 
9.82 
12.74 

42.14 
42.24 
40.87 

1.84 

1.87 
1.98 

Terse  v, 

24.25 

9.86 

8.44 

I2<33 

43.19 

1.  07 

Leader,      

22.66 

0.72 

Q.23 

12.98 

4.3-44 

i.  06 

Magnolia,      

25.58 

8.04 

8.21 

10.68 

45.48 

2.OI 

Milkmaid,     

25.76 

9-O3 

9-3'? 

10.  18 

43.72 

1.98 

Nestle,  

24.2 

9.81 

lO.AQ 

11.66 

41.63 

2.21 

Percelain,      ...             .    . 

24.43 

7.01 

10.42 

12.63 

43-8 

I.7I 

Red  Cross,    ... 

25.97 

7-93 

8.91 

11.93 

43.77 

1.49 

Red  Star,      

25.55 

9.74 

9-^8 

10.87 

42.31 

2.13 

Rival,    .    .    . 

21.6'? 

q.  -?6 

8.72 

11.81 

46.61 

1.87 

Sweet  Clover,  

24.51 

8.31 

8.75 

11.88 

44.58 

1-97 

United  States,  ...... 

30.  29 

7.21 

8.74 

12.04 

39.8 

I.Q2 

It  will  be  seen  by  a  glance  at  these  tables  that  while  the  pro- 
portion of  lactose  and  cane-sugar  in  condensed  milk  is  in  excess 
of  that  found  in  human  or  cow's  milk,  yet  the  amount  of  fat  and 
proteid,  as  well  as  the  alkaline  mineral  matters,  is  considerably 


*  From  Bulletin  No.  10,  Department  of  Agriculture. 


154  FEEDING    AND    FOOD    OF    INFANTS    AND    CHILDREN. 

less.  It  is  true  that  the  large  amount  of  sugar  present  tends  to 
prevent  constipation,  but  the  other  elements  being  disproportion- 
ately small  makes  condensed  milk  deficient  in  its  general  nutritive 
properties  as  an  article  of  food. 

Children  fed  on  condensed  milk  soon  become  fat,  and  for  some 
time  the  digestion  really  seems  to  be  improved  ;  this  is  more 
frequently  the  case  if  the  child  is  changed  to  a  diet  of  this  sub- 
stance from  one  of  farinaceous  foods.  After  a  continued  diet  of 
condensed  milk,  however,  a  child  generally  becomes  flabby,  rest- 
less, or  sleepy,  suffers  from  impaired  digestion  with  considerable 
fermentation,  and  is  apt,  sooner  or  later,  to  drift  into  a  condition 
of  marasmus.  Some  of  the  worst  cases  of  simple  atrophy  that 
we  have  ever  seen  have  been  those  in  which  the  infants  have  been 
fed  for  a  long  time  on  this  form  of  diet.  In  these  children,  also, 
the  period  of  dentition  comes  later,  is  irregular  and  prolonged, 
and  a  strong  tendency  to  rickets  or  a  chronic  state  of  malnutri- 
tion is  manifest.  It  has  also  been  noticed  that  if  children  fed  on 
this  diet  fall  into  a  subacute  diarrhea,  it  is  almost  impossible  to 
save  their  lives. 


CHAPTER  V. 

DISEASES  OF  THE  DIGESTIVE  ORGANS. 

Of  all  the  diseases  of  young  children  with  which  the  physician 
comes  in  contact,  those  referable  to  a  defective  digestion  will 
form  considerably  more  than  half.  In  the  infant  under  a  year 
old,  and  in  the  young  child  up  to  the  period  of  complete  denti- 
tion, these  diseases  are  found  more  commonly  than  any  other. 
The  very  young  child  is  not  so  susceptible  to  acute  fevers  as 
older  children  ;  it  is,  of  course,  not  prone  to  contract  the  various 
ailments  peculiar  to  adult  life,  so  that  we  find  that  dentition,  and 
the  various  pathologic  conditions  associated  therewith  (all  of 
which  are  exaggerated  by  diseased  states  of  the  digestive  tract), 
and  the  acute  and  chronic  affections  of  the  stomach  and  intes- 
tines will  cause  the  largest  amount  of  work  for  the  physician 
during  these  earlier  years  of  childlife.  It  is  of  special  importance, 
therefore,  that  the  physician  who  attempts  to  treat  the  various 
diseases  in  children  shall  be  at  least  moderately  conversant  with 
the  disorders  affecting  the  digestive  tract  of  children  and  the 
causes  on  which  these  diseases  chiefly  depend. 

THE  MOUTH. 

This  orifice  plays  a  very  important  role  in  the  differential 
diagnosis  of  the  acute  exanthemata,  on  account  of  the  fact  that  a 
number  of  eruptions  make  their  appearance  in  the  mouth  two  or 
three  days  before  developing  in  other  parts  of  the  body.  In 
healthy  new-born  infants  the  mucous  membrane  of  the  mouth  is 
of  a  pink  color,  with  a  very  slight  secretion  of  saliva.  This  con- 
tinues for  the  first  two  or  three  months  of  life,  toward  the  end 
of  which  time  the  secretion  becomes  gradually  increased  in 
quantity  because  of  the  higher  development  of  the  salivary 
glands.  Frequently  small  flocculi  or  curds  of  milk  may  be  seen, 
and  occasionally  these  must  be  differentiated  from  the  ulcerative 
patches  of  stomatitis  or  of  thrush.  As  the  epithelium  of  the 
mucous  membrane  is  exceedingly  delicate,  it  can  easily  be  in- 
jured, and  may  become  a  point  of  entrance  for  bacteria,  thus  set- 
ting up  some  form  of  infective  disease. 

155 


156  DISEASES    OF    THE    DIGESTIVE    ORGANS. 


DISEASES   OF   THE    MOUTH. 

STOMATITIS. 

Varieties. — (i)  Simple  catarrhal  stomatitis  ;  (2)  aphthous 
stomatitis  ;  (3)  ulcerative  stomatitis  ;  (4)  stomatitis  mycosa,  or 
parasitic  stomatitis  ;  (5)  gangrenous  stomatitis  ;  (6)  diphtheric 
stomatitis  ;  (7)  syphilitic  stomatitis ;  (8)  mercurial  stomatitis. 

i.  SIMPLE  CATARRHAL  STOMATITIS. 

Catarrhal  stomatitis  consists  of  a  hyperemic  condition  of  the 
mucous  membrane  of  the  mouth,  with  more  or  less  alteration  of 
its  secretion. 

Causes. — The  causes  may  be  primary  or  secondary.  Among 
the  primary  causes  are  traumatism  to  the  mucous  membrane  by 
too  vigorous  attempts  at  cleansing  the  mouth,  by  the  food 
being  too  hot,  in  older  children  by  sharp  teeth,  or  by  an 
irritation  or  abscess  in  the  gum.  As  secondary  causes  we  have 
the  various  gastro-intestinal  diseases,  teething,  eruptive  fevers, 
and  quite  frequently  whooping-cough.  Stomatitis  is  often  found 
in  healthy  children  as  well  as  in  those  who  are  sickly. 

Symptoms. — Preceding  the  onset  of  the  inflammation  in  the 
mouth  we  may  have  a  slight  rise .  of  temperature,  some  vom- 
iting, constipation — symptoms,  in  fact,  showing  the  onset  of 
any  acute  disease.  In  a  short  time  there  will  be  pain  in  the 
mouth  or  throat,  these  symptoms  occasionally  being  accom- 
panied by  enlargement  of  the  lymphatics  under  the  jaw  and  in 
the  neck.  A  slight  cough  not  infrequently  forms  an  accompani- 
ment. These  symptoms  are  quickly  followed  by  soreness  of 
the  mucous  membrane  of  the  mouth,  which  becomes  more  and 
more  localized,  with  increased  salivation  and  fetor  of  the  breath. 

When  the  stomatitis  is  general,  the  lips  share  in  the  inflamma- 
tion, becoming  swollen  and  tense.  A  fine  papular  eruption, 
caused  by  the  engorgement  of  the  muciparous  follicles  of  the 
lips,  is  often  seen.  The  tongue  is  coated,  sometimes  slightly 
swollen. 

Treatment. — A  method  of  treatment  often  pleasant  to  the 
patient  consists  in  the  application  of  cold  sterilized  water  to  the 
interior  of  the  mouth  by  means  of  cotton  fastened  to  a  stick. 
The  action  of  these  applications  can  be  increased  by  the  addition 
of  boric  acid  in  a  strength  of  2  or  3  per  cent.  Weak  solutions  of 
sulphate  of  zinc  or  salicylate  of  soda  in  a  strength  of  about  i  per 


-LG- 
STOMATITIS.  157 

cent,  are  useful  remedies.  The  agent  most  generally  used,  and 
usually  with  excellent  effect,  is  nitrate  of  silver  in  a  strength  of 
about  0.5  to  1.5  per  cent. 

Applications  of  alum,  made  by  gently  touching  the  inflamed 
spot  with  a  single  crystal,  sometimes  give  good  results.  The 
food  should  be  bland,  and  all  condiments  should  be  avoided.  It 
is  often  more  grateful  to  the  patient  to  have  the  food  given  cold. 
Attention  should  be  directed  to  the  digestion,  and  the  bowels 
be  kept  open  by  laxatives. 

2.  APHTHOUS  STOMATITIS. 

Synonyms. — VESICULAR  STOMATITIS  ;  FOLLICULAR  STOMATITIS  ; 
APHTHOUS  SORE  MOUTH. 

Aphthous  stomatitis  consists  in  a  hyperemia  of  the  mucous 
membrane  of  the  mouth,  accompanied  by  the  formation  of  small 
superficial  ulcers. 

Causes. — Aphthous  stomatitis  is  most  common  from  the 
tenth  to  the  thirteenth  month  of  life,  although  it  may  occur  at 
any  age.  The  direct  causes  are  rather  obscure,  although  micro- 
organisms would  seem  to  play  an  important  part  in  the  etiol- 
ogy. Siegel  describes  an  ovoid  bacillus  0.5  //in  length,  which 
he  found  in  the  buccal  secretion  taken  from  patients  seen  dur- 
ing an  epidemic  in  Germany.  The  disease  frequently  follows 
gastro-intestinal  diseases,  acute  fevers,  and  pneumonia.  Preced- 
ing the  inflammation  of  the  mouth  the  symptoms  of  high  fever, 
increased  salivation,  vomiting,  and  constipation — in  fact,  the 
same  symptoms  which  may  precede  any  of  the  acute  fevers — may 
be  present.  The  heat  and  pain  in  the  mouth  increase  and  there 
may  be  some  enlargement  of  the  lymphatics.  The  inflammation 
of  the  mouth  soon  localizes  itself  into  small  ulcers  of  round  or 
oval  shape  and  of  yellowish-white  color,  each  ulcer  being  sur- 
rounded by  a  red  areola.  The  ulcers  may  appear  simultane- 
ously, or  they  may  come  in  successive  crops. 

Treatment. — The  treatment  consists  in  opening  the  bowels 
with  a  gentle  laxative  and  regulating  the  diet.  In  this  form  of 
stomatitis  applications  of  chlorate  of  potassium,  in  the  strength 
of  from  twenty  to  twenty-five  grains  to  the  ounce,  seem  to 
work  remarkably  well.  The  cause  of  the  inflammation,  so  far 
as  possible,  should  be  removed  ;  the  roots  of  decayed  teeth  should 
be  taken  out,  and  diseased  teeth  attended  to.  The  local  treat- 
ment consists  in  the  application  of  chlorate  of  potassium  or  silver 
nitrate.  Since  many  of  the  children  affected  by  this  disease  are 
in  poor  general  health,  tonics,  such  as  the  various  preparations 


158  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

of  iron  and  quinin,  are  indicated.  When  the  mouth  is  so  sore 
that  food  can  not  be  taken  in  this  way,  nutritive  enemata  should  be 
used.  The  irritation  caused  by  the  highly  acid  secretion  of  the 
mouth  may  be  relieved  by  gently  washing  out  with  a  solution  of 
borax  or  bicarbonate  of  soda.  The  mouth  must  be  kept  clean, 
but  it  should  be  borne  in  mind  that  all  applications  must  be  ap- 
plied with  great  care. 

A  form  of  aphthous  stomatitis  only  found  in  the  new-born  and 
described  under  the  name  of  Bednar's  aphthae  consists  in  a 
number  of  shallow  ulcers  covered  by  a  gray  or  yellowish  coat- 
ing, which  are  found  upon  the  soft  palate  and  the  posterior  part 
of  the  hard  palate.  This  form  of  aphthae  is  always  produced  by 
a  too  violent  cleansing  of  the  mouth,  although  it  is  occasionally 
found  resulting  from  the  use  of  badly  shaped  rubber  nipples 
(Forchheimer).  The  treatment  consists  in  the  application  of 
bland  antiseptic  washes. 


3.  ULCERATIVE   STOMATITIS. 

"  This  is  a  peculiar  process,  characterized  by  destruction  of 
tissue,  beginning  on  the  gums  around  the  teeth,  never*  extending 
beyond  the  mouth,  infecting  healthy  parts  of  the  mouth,  and 
never  occurring  where  there  are  no  teeth  "  (Forchheimer). 

Causes. — Ulcerative  stomatitis  is  rarely  found  in  children 
under  five  years  of  age  unless  produced  artificially  by  such  drugs 
as  mercury.  It  usually  occurs  in  children  living  amid  bad 
hygienic  surroundings,  particularly  when  these  are  associated 
with  poor  nourishment.  It  is  occasionally  seen  following  such 
diseases  as  scarlet  fever  or  measles,  although  it  is  possible  for  it 
to  occur  in  any  condition  in  which  the  health  is  greatly  depre- 
ciated. It  is  generally  considered  to  be  noncontagious.  A 
mild  form  of  ulcerative  stomatitis  of  scorbutic  origin  is  occasion- 
ally met  in  infants  who  have  been  fed  on  sterilized  milk  for  a  long 
time. 

Symptoms. — The  disease  usually  commences  with  an  inflam- 
mation of  the  gums  surrounding  the  incisors,  and  is  most  apt  to 
affect  those  of  the  lower  jaw.  The  gums  become  swollen,  red, 
and  spongy.  In  a  short  time  a  line  of  ulcers  extends  from  the 
point  of  origin  around  the  gums  to  the  cheek.  These  ulcers 
are  usually  gray  in  color,  although  occasionally  they  are  of  a 
yellowish  hue.  In  a  short  time  sloughing  of  the  tissue  follows 
and  the  teeth  become  detached  from  the  gums,  the  resulting 
cavity  being  filled  with  a  mucopurulent  secretion.  The  quantity 
of  saliva  is  increased,  and  this  secretion,  becoming  mixed  with 


STOMATITIS.  159 

discharges  from  the  ulcers,  produces  a  peculiar  fetid  odor  in  the 
saliva  and  breath.  In  very  bad  cases  the  maxillary  bones 
themselves,  particularly  the  inferior  one,  may  be  attacked.  An 
eczematous  eruption  may  appear  around  the  lips,  caused  by  the 
irritation  of  the  saliva.  The  submaxillary  lymphatics  become 
enlarged,  but  this  enlargement  rarely  tends  to  suppuration. 

In  very  bad  cases  the  tongue  and  the  entire  mucous  mem- 
brane may  become  affected,  and  the  part  of  the  latter  covering 
the  gum  of  the  lower  jaw  may  be  entirely  destroyed  by 
ulceration.  This  is  the  form  of  stomatitis  which  is  most 
commonly  associated  with  scorbutus. 

The  prognosis  depends  on  the  extent  of  the  disease.  When 
scurvy  is  the  cause,  or  when  any  great  destruction  of  bone  has 
occurred,  the  prognosis  is  grave. 

Treatment. — The  treatment  is  both  prophylactic  and  cura- 
tive. The  prevention  of  the  disease  is  accomplished  by  im- 
proving, so  far  as  possible,  the  hygienic  surroundings  of  the 
patient  and  by  the  judicious  use  of  good  food  and  tonics. 
According  to  many  authorities,  chlorate  of  potassium  is  regarded 
as  almost  a  specific  in  the  disease.  It  should  be  given  in  about 
3  per  cent,  solutions,  the  effects  of  the  drug  being  carefully 
watched.  A  very  good  formula  recommended  by  Starr  is  as 
follows  : 

Potassium  chlorate, 58  grains 

Dilute  hydrochloric  acid, I  fluidram 

Syrup, y^.  fluidram 

Water, to  make     3  fluidrams. 

SIG. — One  teaspoonful,  diluted  in  water,  for  a  child  three  years  old. 

When  this  disease  is  associated  with  carious  teeth,  or  if  the 
bone  has  become  involved,  the  affected  structures  must  be  re- 
moved. When  extreme  fetor  of  the  breath  occurs,  the  mouth 
should  be  washed  out  with  weak  solutions  of  permanganate  of 
potash  or  a  solution  of  the  hypochlorites.  In  some  cases 
alcoholic  stimulants  are  indicated.  Unquestionably,  chlorate  of 
potassium  is  the  most  successful  remedy  in  this  disease. 

4.  STOMATITIS  MYCOSA  OR  PARASITIC  STOMATITIS. 
Synonyms. — THRUSH  ;  SOOR  ;  MUGUET  ;  SPRUE  ;  MILLET. 

The  disease  consists  of  a  yellowish-white  growth  of  parasitic 
origin,  occurring  on  the  mucous  membrane  of  the  mouth. 

Causes. — The  direct  cause  of  mycotic  stomatitis  is  the  oidium 
albicans.  It  is  probable  that  this  fungus  is,  in  the  majority  of 


l6o  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

cases,  carried  into  the  mouth  by  the  nipple  or  the  nursing-bottle. 
Either  healthy  or  unhealthy  children  may  have  the  disease,  but 
those  who  have  had  some  slight  catarrhal  inflammation  of  the 
mouth  are  especially  predisposed  to  it.  Thrush  is  especially 
found  in  poorly  nourished  infants  and  in  those  who  are  bottle- 
fed.  Any  cause  producing  mechanical  injury  to  the  mouth  will 
predispose  to  the  development  of  thrush  fungus.  Like  other 
forms  of  stomatitis,  it  may  occur  in  children  recovering  from 
some  prolonged  illness. 

Symptoms. — Quite  often  there  are  no  premonitory  symptoms 
of  thrush,  the  spots  themselves  being  the  first  indication  of  the 
disease.  These  are  of  a  grayish-white  color,  of  variable  size,  and 
rest  on  the  mucous  membrane,  occasionally,  but  not  always, 
being  elevated  above  the  surface.  They  appear  first  on  the  in- 
ternal surface  of  the  cheeks  and  dorsum  of  the  tongue,  and  then 
extend  backward  to  the  soft  palate  or  forward  to  the  lips.  The 
patches  have  occasionally  been  found  in  the  pharynx  and  esoph- 
agus. An  examination  of  these  patches  by  reflected  light  shows 
them  to  be  developed  within  the  epithelium,  each  being  sur- 
rounded by  a  narrow  ring  of  injected  blood-vessels.  As  devel- 
opment progresses  the  spot  is  pushed  up  above  the  level  of  the 
mucous  membrane.  Occasionally  the  upper  coat  of  a  spot  will 
drop  off,  leaving  quite  a  deep  ulcer.  In  bad  cases  a  number  of  these 
ulcers  will  become  confluent,  their  covering  of  fungus  forming  a 
sort  of  membrane.  Microscopic  examination  of  scrapings  taken 
from  these  spots  will  demonstrate  the  presence  of  saccharomyces 
or  the  oidium  albicans. 

Treatment. — The  prophylactic  treatment  of  parasitic  stoma- 
titis consists  in  careful  attention  to  the  mouth  of  the  child,  the 
avoidance  of  all  forcible  attempts  at  cleanliness,  and  of  abrasions 
of  the  mucous  membranes.  The  nursing-bottle  and  nipple  must 
be  kept  antiseptically  clean. 

The  curative  treatment  consists  in  the  application  to  the 
mucous  membrane  of  solutions  of  borax  or  bicarbonate  of  soda, 
either  mixed  with  water  or  some  syrup.  A  very  good  prescrip- 
tion is  the  following  : 

R.      Acid,  carbolic., gr.  ij 

Sodii  salicylas, 

Sodii  biboras aa     gr.  xxx 

Glycerin, %\] 

Aqua  rosse, q.  s.  ad  f  Jjj. 

SlG. — For  local  application. 


STOMATITIS.  l6l 


5.  GANGRENOUS  STOMATITIS. 

Synonyms. — CANCRUM  ORIS  ;  NOMA  ;  ORAL  GANGRENE  ; 
WANGENBRAND. 

Gangrenous  stomatitis  consists  in  a  rapidly  developing  inflam- 
mation of  the  cheek  and  adjacent  tissues,  accompanied  by 
gangrene  and  destruction  of  the  affected  parts. 

Causes. — This  form  of  inflammation  of  the  mouth  is  rarely 
seen  in  children  under  two  years  of  age.  From  the  second  until 
the  twelfth  year  is  the  period  during  which  it  is  most  likely 
to  occur.  Although  the  origin  is  somewhat  obscure,  it  is 
possible  that  it  may  be  microbic.  From  the  manner  in  which  it 
occurs,  several  cases  in  the  same  hospital  being  affected  at  one 
time,  it  would  seem  that  there  might  be  an  infectious  element  in 
its  causation.  It  is  most  common  in  debilitated  children — those 
long  suffering  from  improper  food  and  bad  hygienic  surround- 
ings or  from  the  results  of  some  infectious  disease.  It  is  said  to  be 
particularly  common  after  measles  and  typhus  fever,  although  it 
is  not  uncommon  after  any  of  the  acute  exanthemata.  The 
excessive  use  of  mercury  is  also  an  occasional  cause. 

Pathology. — Cancrum  oris  presents  all  the  pathologic 
changes  of  acute  phlegmonous  gangrene  in  any  other  part  of  the 
body.  We  have  here,  as  in  other  forms  of  gangrene,  the  three 
zones  :  In  the  center  is  the  zone  of  blackened,  destroyed  tissue, 
around  the  outer  margin  of  which  can  be  seen  the  second  zone, 
consisting  of  connective -tissue  cells  in  a  state  of  active  division. 
The  blood-vessels  will  be  found  closed  by  thrombi  consisting  of 
various  forms  of  microbic  life.  The  third  or  outer  zone  consists 
of  healthy  tissue. 

Symptoms. — During  or  following  convalescence  from  one  of 
the  acute  fevers,  or  in  a  debilitated  child,  a  small  nodule,  some- 
what hard  and  sensitive,  will  appear  on  the  gum  or  on  one 
of  the  cheeks.  The  skin  or  mucous  membrane  surrounding  it 
will  be  either  hard  and  swollen  or,  as  is  not  infrequently  seen 
when  the  disease  attacks  the  cheek  first,  there  is  simple  swell- 
ing accompanied  by  considerable  edema  of  the  affected  part. 
Although  pain  is  usually  complained  of,  there  is  occasionally 
very  little  discomfort  connected  with  the  progress  of  this  disease. 
The  mucous  membrane  underlying  the  external  swelling  puffs 
up,  forming  a  vesicle  which  is  filled  by  an  ichorous  fluid.  This 
vesicle  rapidly  changes  into  a  gangrenous  ulcer  of  a  blackish 
or  reddish-brown  hue.  The  lymphatics  of  the  neck  quickly 
become  infiltrated  on  the  same  side  as  the  affected  cheek.  The 


l62 


DISEASES    OF    THE    DIGESTIVE    ORGANS. 


skin  of  the  cheek  changes  to  a  bluish  color  over  the  point  of 
primary  induration.  The  ulcer  rapidly  deepens  and  spreads, 
first  perforating  the  cheek,  then  continuing  the  destruction  of 
tissue  until  the  entire  side  of  the  face  is  destroyed.  The  disease 
may  involve  the  whole  of  the  cheek,  the  neck,  and  even  the  eye 
on  one  side,  but  it  very  rarely  becomes  bilateral ;  the  bones 
and  teeth  of  the  infected  side  are  entirely  laid  bare.  Gangrene 
of  the  mouth  is  accompanied  by  great  constitutional  depression. 


. 

FIG.  19. — GANGRENOUS  STOMATITIS. — (Dr.  Stengel's  case  at  the  Children's  Hospital.) 


The  temperature  is  variable :  sometimes  considerable  fever  is 
found,  but  as  the  disease  progresses,  and  septicemic  symptoms 
arise  we  usually  find  the  fever  assuming  the  character  found  in 
septicemia  elsewhere. 

Before  death  occurs  the  temperature  is  occasionally  sub- 
normal. The  sequelae  of  the  disease  are  septic  pneumonia, 
caused  by  the  inspiration  of  infected  material,  and  diarrhea,  also 


STOMATITIS.  163 

of  septic  origin.  Diphtheria  has  been  observed  in  a  number  of 
cases.*  As  the  blood-vessels  of  the  affected  part  are  usually 
filled  with  thrombi,  perforation  of  these  very  rarely  causes 
hemorrhage.  Spontaneous  recovery  from  this  disease  is  ex- 
tremely rare,  the  mortality  being  given  as  from  70  to  90  per 
cent,  of  all  cases  affected. 

Treatment. — The  best  treatment  of  gangrenous  stomatitis 
lies  in  its  prevention.  With  this  object  in  view,  a  child  sick 
with  any  of  the  infectious  fevers  should  be  placed  amid  the 
best  hygienic  surroundings  and  its  general  health  kept  in  as 
good  order  as  possible  by  tonics  and  nourishing  food.  When 
the  disease  has  once  started,  the  system  should  be  stimulated 
by  concentrated  nourishment,  such  as  meat,  milk,  eggs,  etc. 
Alcoholic  stimulants  are  particularly  indicated  here,  as  in  any 
form  of  septic  infection.  The  gangrene  should  be  kept  from 
spreading  by  a  thorough  cauterization  of  the  tissues  immediately 
surrounding  the  ulcer.  This  can  best  be  done  by  the  use  of  the 
Paquelin  cautery,  the  galvanocautery,  caustic  soda,  or  fuming 
nitric  acid.  In  order  to  lessen  the  horrible  stench  which  arises 
from  the  gangrenous  tissue  the  mouth  should  be  swabbed  out 
thoroughly  and  the  ulcer  treated  with  permanganate  of  potash, 
carbolic  acid,  pure  peroxid  of  hydrogen  (the  latter  is  very 
useful),  or  iodoform  and  bismuth. 

6.  DIPHTHERIC  STOMATITIS  (CROUPOUS  STOMATITIS). 

This  rare  form  of  stomatitis  may  be  of  primary  or  secondary 
origin.  When  primary,  the  point  of  development  of  the  mem- 
brane is  usually  on  the  lips,  extending  thence  to  any  part  of  the 
mouth.  Secondarily  it  may  spread  from  an  infected  tonsil  to 
the  lips,  gums,  or  cheeks.  A  form  of  croupous  stomatitis  may 
arise  from  excessive  use  of  irritating  drugs  used  as  mouth- 
washes.  In  the  true  form  of  diphtheric  stomatitis  the  Klebs- 
Loeffler  bacillus  will  be  found. 

Symptoms. — When  the  disease  is  of  true  diphtheric  origin, 
the  symptoms  will  be  those  of  ordinary  diphtheria.  Occasionally 
the  symptoms  are  obscure,  and  the  ulcers  may  be  well  developed 
before  they  are  discovered.  The  duration  of  the  membrane  is 
usually  from  three  to  six  days,  although  it  may  last  longer. 
Salivation  usually  forms  an  accompanying  symptom,  both  it  and 
the  breath  having  a  strong  fetid  odor.  As  the  membrane  sepa- 

*In  an  epidemic  of  measles  at  St.  Vincent's  Home,  under  our  observation  at  the 
present  time,  diphtheria  complicates  half  the  cases,  and  five  deaths  have  occurred 
from  cancrum  oris.  Two  patients  affected  with  the  disease  have  recovered. 


164  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

rates  there  may  be  more  or  less  hemorrhage,  caused  by  the 
exposure  of  small  blood-vessels  which  have  been  eaten  into  by 
the  disease.  This  hemorrhage  may  sometimes  be  quite  severe. 
Treatment. — The  treatment  is  the  same  as  that  of  ordinary 
diphtheria.  When  it  is  possible,  the  membrane  should  be  care- 
fully removed  and  the  remaining  ulcer  washed  thoroughly  with 
corrosive  sublimate,  peroxid  of  hydrogen,  or  Loeffler's  solution. 
In  the  croupous  form,  resulting  from  irritation,  soothing  antisep- 
tic washes  should  be  used.  Treatment  by  the  use  of  injections 
of  antitoxin  should  always  be  resorted  to,  and  the  system  sup- 
ported by  tonics  and  good  food. 

SYPHILITIC  STOMATITIS. 

The  primary  infection  of  syphilis  may  occur  in  the  mouth, 
the  usual  site  of  the  chancre  in  this  case  being  the  lips.  The 
origin  of  the  infection  is  usually  by  transmission  from  a  wet- 
nurse  having  the  disease.  The  evidences  of  secondary  syphilis 
of  the  mouth  are  not  at  all  uncommon,  and  may  be  found 
on  any  part  of  the  mucous  membrane.  The  most  common 
forms  are  those  known  as  syphilitic  fissures  or  rhagades.  These 
usually  occur  at  the  angles  of  the  mouth  or  upon 'the  upper 
or  the  lower  lip  ;  they  may  be  single  or  multiple,  and  cause  con- 
siderable pain.  These  fissures  are  very  slow  to  heal  spontane- 
ously, and  even  after  this  has  taken  place  they  generally  leave 
a  disfiguring  scar.  Syphilitic  papules  are  also  found  quite  com- 
monly, their  seat  being  the  commissure  of  the  mouth  and  the 
free  borders  of  the  lips.  If  these  split,  they  may  resemble  the 
former  variety  quite  closely.  In  their  elevation,  position,  and  in 
the  moisture  which  covers  their  surface  they  resemble  condylo- 
mata  lata.  The  ordinary  mucous  patch  of  syphilis  may  also  be 
found,  either  on  any  part  of  the  mucous  membrane  lining  the 
mouth  or  on  the  tongue. 

Treatment.— The  treatment  is  that  of  syphilis  generally. 
The  affected  parts  should  be  treated  by  applications  of  corrosive 
sublimate,  either  in  the  strong  solution,  applied  with  a  brush,  or 
in  a  weaker  form,  to  be  used  as  a  mouth-wash. 

7.  MERCURIAL  STOMATITIS  (PTYALISM). 

This  consists  in  an  inflammation  of  the  mucous  membrane  of 
the  mouth,  attended  by  a  great  increase  in  the  quantity  of  saliva 
and  an  alteration  in  the  character  of  the  secretion. 

Causes. — The  most  common  cause  is  the  administration  of 
too  large  a  dose  of  mercury,  long-continued  use  of  the  drug,  or 
an  unnatural  susceptibility  of  the  patient. 


THE    TONGUE.  165 

Symptoms. — The  first  manifestation  of  ptyalism  is  an  extreme 
tenderness  of  the  gums,  this  being  particularly  felt  in  biting  or 
in  snapping  the  jaws  together.  The  gums  soon  become  red  and 
swollen,  the  latter  being  greatest  at  the  point  of  insertion  of  the 
teeth.  There  is  usually  a  metallic  taste  in  the  mouth,  although 
in  children  this  will  not  often  be  complained  of,  because  the 
patient  is  too  young  to  associate  cause  with  effect.  The  secre- 
tion of  saliva  becomes  profuse,  so  that  the  patient  is  continually 
endeavoring  to  expectorate.  The  breath  is  fetid,  the  tongue 
swollen,  and  if  the  poisoning  is  severe,  the  tongue  may  even 
protrude  from  the  mouth.  Ulcerative  stomatitis  may  follow, 
and  loosening  and  dropping  out  of  the  teeth  sometimes  occur  in 
severe  cases.  Complete  necrosis  of  the  maxillary  bone  occa- 
sionally follows. 

Treatment. — The  first  indication  of  treatment  is  to  stop  the 
administration  of  mercurials.  In  order  to  increase  elimination 
small  doses  of  potassium  iodid  may  be  used,  and  this  may 
further  be  aided  by  the  use  of  saline  laxatives.  Frequent  bath- 
ing and  friction  of  the  skin  will  help  in  this  object.  In  order  to 
check  the  hypersecretion  of  saliva  small  doses  of  belladonna 
will  be  found  useful.  When  the  pain  and  distress  are  great, 
opium  may  be  used,  although  great  care  must  be  exercised  in 
the  administration  of  this  drug,  particularly  to  young  children. 

THE  TONGUE. 

Parenchymatous  inflammation  of  the  organ  (glossitis)  is  quite 
rare  in  children,  but  the  tongue  and  mouth  often  act  as  indicators 
for  diseases  in  other  parts  of  the  body.  Thus  we  have  a  blue 
tongue  as  a  symptom  of  cyanosis  ;  the  pale  or  colorless  tongue 
seen  after  severe  hemorrhage  or  in  conditions  of  anemia ;  the 
coated  tongue  found  in  all  diseases  of  the  digestive  tract ;  the  red 
and  glazed  tongue,  with  its  border  of  coating,  seen  in  certain 
fevers.  It  should  be  remembered,  however,  that  no  special 
organisms  have  been  found  in  the  fur  of  the  tongue,  and  it  would 
be  futile  to  speak  of  any  specific  coatings  for  any  one  given 
disease. 


DISEASES  OF  THE  TONGUE. 

The  tongue  may  be  congenitally  above  or  below  the  normal 
size,  the  former  condition  being  known  as  macroglossia  and  the 
latter  as  microglossia. 

The  first  is  usually  found  in  two  forms  :  (i)  The  fibrinous, 


1 66  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

in  which  the  connective  tissue  of  the  organ  is  increased.  (2) 
"  A  cavernous  cystoid  degeneration  of  the  interstitial  connective 
tissue,  by  which  the  resulting  spaces  come  into  connection  with 
the  lymph-vessels,  constituting  a  condition  closely  resembling 
cavernous  angioma,  from  which  it  receives  its  name  of  lymphan- 
gioma  cavernosum"  (Rotch). 


FIBRINOUS  MACROGLOSSIA. 

Symptoms. — The  tongue  is  much  enlarged,  is  of  a  bluish  or 
violet  color,  and  is  generally  covered  with  a  whitish  or  grayish 


FIG.  20. — MACROGLOSSIA. — (Dr.  W.  W.  Keen's  Case.) 

coat  Indentations  or  ulceration  of  the  organ,  especially  along 
the  edges,  may  occur  from  pressure  of  the  teeth.  From  the  size 
of  the  tongue  respiration  and  deglutition  may  be  interfered  with. 
The  lips,  and  especially  the  lower  one,  become  thick,  edematous, 
or  ulcerated,  and  salivation  is  always  present.  Macroglossia 
is  most  frequently  found  in  deformed  subjects  or  cretins. 

Treatment. — The  treatment  is  usually  palliative.  The  tongue 
should  be  kept  clean  with  warm,  slightly  alkaline  solutions,  or 
when  the  organ,  by  its  size,  threatens  the  stoppage  of  respiration 
or  deglutition,  part  of  it  should  be  removed. 


GLOSSITIS RANULA.  l6/ 

A  rare  condition,  known  as  lingua  gcograpJiica,  or  "  mappy 
tongue,"  has  been  described.  The  symptoms  are  the  appearance 
of  one  or  more  small  patches  on  the  dorsum  of  the  tongue, 
these  patches  frequently  spreading,  uniting  so  that  the  entire 
surface  of  the  organ  may  be  covered.  The  patches  are  red  in 
color,  smooth,  and  the  filiform  papillae  are  absent.  The  unaf- 
fected portions  of  the  tongue  are  normal,  except  that  the  papillae 
on  the  borders  of  the  denuded  portions  are  white  and  prominent. 
The  condition  has  no  special  significance  and  needs  no  treat- 
ment. 

GLOSSITIS. 

Definition. — An  acute  inflammation  of  the  parenchyma  of  the 
tongue. 

Symptoms. — Pain  and  swelling  of  the  organ,  accompanied 
by  a  rise  of  temperature  and  a  hypersecretion  of  saliva.  Oc- 
casionally enlargement  of  the  tongue  may  interfere  with  respira- 
tion. 

Causes. — The  disease  usually  arises  from  direct  injury  to  the 
tongue,  as  in  the  swallowing  of  irritating  substances.  The  in- 
flammation may  occasionally  be  septic  in  origin. 

Treatment. — The  treatment  is  purely  symptomatic,  depend- 
ing upon  the  cause. 

RANULA. 

Ranula  is  a  cystic  tumor  of  varying  size,  found  on  one  or  the 
other  side  of  the  frenum  of  the  tongue.  The  tumor  is  semi- 
translucent,  soft,  and  over  it  are  seen  dilated  veins.  Its  contents 
consist  of  a  clear,  glairy  fluid  of  mucoid  character.  Its  cause  is 
in  some  cases  rather  obscure.  It  is  probable  that  it  is  due  to 
dilatation  of  the  ducts  of  the  salivary  glands  or  to  an  obstruction 
of  the  ducts  of  the  sublingual  mucous  glands.  These  tumors 
generally  give  rise  to  little  or  no  pain.  They  are  rather  rare  in 
childhood. 

Treatment. — The  contents  of  the  cyst  should  be  emptied, 
and  as  recurrence  is  one  of  the  characteristics  of  this  form  of 
tumor,  it  is  necessary  to  destroy  the  lining  membrane  by  the  use 
of  caustic.  It  has  been  recommended  that  fifteen  minims  of  a 
mixture  of  tincture  of  iodin  and  water,  of  each  ten  parts,  with  iodid 
of  potassium  one  part,  will  prevent  the  cyst  from  filling  again.  It 
is  probable,  however,  that  a  more  satisfactory  result  can  be 
obtained  by  the  application  of  nitrate  of  silver  to  the  sac  after  its 
contents  have  been  removed. 


1 68  DISEASES    OF    THE    DIGESTIVE    ORGANS. 


DENTITION,  NORMAL  AND    DELAYED. 

Physiology  of  the  Development  of  the  Teeth. — At  about 
the  seventh  week  of  intra-uterine  life  the  stratified  epithelium  of 
the  mucous  membrane  of  the  two  maxillae  becomes  thickened, 
forming  a  ridge.  This  process  passes  downward  into  a  recess  of 
the  developing  embryonic  jaw,  and  is  known  as  the  enamel  groove. 
The  downward  growth,  or  invagination,  of  the  epithelium  forms 
what  is  known  as  the  enamel  germ,  its  position  being  indicated 
by  a  slight  groove  in  the  mucous  membrane  of  the  jaw.  Next 
we  find  the  enamel  groove  and  enamel  germ  elongating  down- 
ward, the  deeper  part  declining  outward,  forming  an  angle 
to  the  upper  portion  or  neck.  After  this  there  is  an  increased 
development  at  certain  points  corresponding  to  the  situation  of 
the  future  milk-teeth.  The  common  enamel  germ  now  becomes 
divided  at  it's  deeper  portion  into  a  number  of  divisions,  each 
forming  what  may  be  called  a  special  enamel  germ,  which  corre- 
sponds to  what  will  later  be  the  milk-teeth,  or,  more  properly,  each 
enamel  germ  will  later  form  an  individual  tooth  contained  in  its 
own  dental  sac.  About  this  time  there  grows  up  from  the  under- 
lying tissue  into  each  enamel  germ  a  distinct  vascular  papilla, 
known  as  the  dental  papilla,  and  upon  it  the  enamel  germ  adheres. 
This  enamel  germ  consists  of  three  layers,  or,  as  it  is  sometimes 
described,  as  two  layers  of  epithelium  separated  by  an  interval. 
While  part  of  the  subepithelial  tissue  is  elevated  to  form  the 
dental  papillae,  the  part  which  bounds  the  embryonic  teeth  forms 
the  dental  sacs,  and  the  embryonic  jaw,  which  at  first  is  merely  a 
groove  of  bone  in  which  the  dental  germs  lie,  now  sends  up  pro- 
cesses, forming  divisions  or  partitions  separating  the  teeth  from 
one  another.  The  papilla  is  composed  of  nucleated  cells  arranged 
in  a  meshwork,  the  outer  or  peripheral  part  of  which  is  covered 
with  a  layer  of  special  columnar  nucleated  cells  called  odonto- 
blasts  ;  these  latter  form  the  dentin,  while  the  remainder  of  the 
papilla  forms  the  tooth-pulp.  As  the  dentin  increases  in  thick- 
ness the  papillae  diminish  in  size,  and  when  the  tooth  is  cut,  only  a 
small  amount  remains  as  the  dental  pulp,  and  in  this  run  the  blood- 
vessels and  branches  of  the  inferior  dental  nerve,  which  enter  the 
tooth  at  the  inferior  extremity  of  each  fang.  The  enamel  consists 
of  three  parts  :  (i)  An  inner  membrane  composed  of  a  layer  of 
columnar  epithelium  in  contact  with  the  dentin,  called  enamel 
cells  ;  external  to  this  we  find  one  or  more  layers  of  small  poly- 
hedral nucleated  cells  ;  (2)  an  outer  membrane  consisting  of  sev- 
eral layers  of  epithelium  ;  (3)  lastly,  a  middle  membrane,  formed 


DENTITION,    NORMAL    AND    DELAYED.  169 

of  a  matrix  of  nonvascular,  gelatinous  tissue  containing  a  hyaline 
interstitial  substance.  The  enamel  is  formed  by  the  enamel  cells 
of  the  outer  membrane.  The  development  of  the  teeth  progresses 
steadily  from  birth  during  the  whole  period  of  infant  life.  As 
each  tooth,  contained  in  its  dental  sac  and  set  in  its  small  cavity 
of  bone,  develops,  elongation  takes  place,  beginning  at  the  fang. 
In  its  growth  the  tooth  follows  the  path  of  least  resistance,  which 
is  always  toward  the  mucous  membrane,  which  at  the  period 
of  birth  covers  it.  Finally,  from  pressure  against  the  mucous 
membrane,  atrophy  or  absorption  of  the  latter  takes  place  and 
the  tooth  appears  above  the  level  of  the  mucous  membrane. 

As  the  child  advances  in  years  the  temporary  or  milk-teeth 
are  gradually  replaced  by  the  permanent  teeth,  which  push  their 
way  up  from  beneath  the  former,  absorbing  in  their  growth  the 
whole  of  the  fang  of  each  of  the  first  set  until  little  is  left  except 
the  crown,  which  finally  comes  away. 

The  age  at  which  the  first  tooth  appears  varies  considerably, 
this  difference  depending  upon  many  causes.  As  a  general  rule, 
in  healthy  children  the  first  tooth  appears  about  the  sixth  to 
the  eighth  month.  The  eruption  of  the  teeth  begins  later  in 
children  affected  by  rachitis,  syphilis,  or  tuberculosis,  or  in  those 
who  may  be  classified  under  a  general  head  as  being  "  feeble 
children."  The  lower  central  incisor  usually  appears  first, 
and  from  this  time  dentition  may  be  divided  into  five  periods, 
between  each  of  which  is  an  interval  of  varying  length,  some- 
times known  as  interdental  intervals.  The  first  period  occu- 
pies the  time  when  the  two  lower  incisors  are  cut.  In  the 
second  period 'the  four  upper  incisors  make  their  appearance,  these 
being  followed  very  often  by  an  interval  of  several  weeks.  The 
third  period  is  that  in  which  the  lower  lateral  incisors  and  the 
anterior  molars  of  the  upper  and  lower  jaw  are  cut ;  this  lasts  from 
the  twelfth  to  the  fourteenth  month,  and  is  usually  followed  by 
quite  a  long  interval  of  rest.  The  fourth  period  begins  at  about 
the  eighteenth  or  twentieth  month,  and  it  is  at  about  this  time 
that  the  canines  appear.  The  fifth  period  occurs  at  two  and  a 
half  years  of  age,  when  the  posterior  molars  are  cut.  The  entire 
"  milk-set "  is  composed  of  twenty  teeth,  ten  in  each  jaw, 
arranged  as  follows : 

DENTAL  PERIODS.  AGE.  GROUP  OF  TEETH. 

I, 6  to  8  months,  Two  middle  lower  incisors. 

II, 8  to  10       "  Four  upper  incisors. 

Ill, 12  to  14       "  Two  lower  lateral  incisors 

and  four  first  molars. 

IV, 18  to  20       "  Four  canines. 

V, 281032       "  Four  second  molars. 


170 


DISEASES    OF    THE    DIGESTIVE    ORGANS. 


At  birth  the  jaw  contains  the  entire  milk-set,  the  crowns  of 
which  are  calcified.  Besides  these  there  is  one  member  of  the 
second  set — the  six-years-old  molar — the  calcification  of  which 
begins  during  uterine  life,  at  about  the  sixth  month.  The  per- 
manent incisors  begin  to  calcify  during  the  first  month  of  life  ;  the 
canines  in  the  first  or  second  year.  Calcification  of  the  crown  of 
the  second  molar  is  completed  about  the  fourth  year,  and  of  the 
third  permanent  molar,  or  wisdom-tooth,  at  from  seventeen  to 
twenty-five  years.  Thirty-two  teeth  in  all  comprise  the  second 
or  permanent  set,  and  during  their  development  the  jaws  increase 
in  length  to  provide  for  the  greater  number  of  teeth.  The  sec- 
ond dentition  can  not  be  divided  into  so  clearly  marked  periods 
as  the  first,  but  the  ages  at  which  the  teeth  make  their  appearance 
are,  generally  speaking,  as  follows  (it  must  be  remembered,  ho\v- 


FIG.  2i.— DIAGRAM  SHOWING  THE  ORDER  OF  THE  ERUPTION  OF  THE  MILK-TEETH. 


ever,  that  many  causes  which  delay  the  eruption  of  the  first  teeth 
will  also  retard  the  second  set)  : 

YEARS.  GROUPS. 

Six, Four  first  molars. 

Seven, Four  middle  incisors. 

Eight, Four  lateral  incisors. 

Nine, Four  first  bicuspids. 

Ten, Four  second  bicuspids. 

Eleven, Four  canines. 

Twelve, Four  second  molars. 

Seventeen  to  twenty-five, Four  third  molars  (wisdom-teeth). 

Dentition  being  a  physiologic    process,  there  should  be  no 


DENTITION,    NORMAL    AND    DELAYED. 


I/I 


symptoms  of  a  pathologic  nature  which  can  be  attributed  to  it. 
It  is  true  that  various  disorders,  principally  referable  to  the 
nervous  system,  the  respiration,  the  skin,  the  digestive  system, 


FIG.  22. — DIAGRAM  SHOWING  THE  ORDER  OF  ERUPTION  OF  THE  PERMANENT  TEETH. 

— ( From  Rotch . ) 

and  organs  of  special  sense,  have  been  associated  with  it,  but  if 
the  child  at  the  time  of  dentition  is  in  a  thoroughly  healthy  con- 
dition, there  should  be  no  bad  symptoms  other  than  some  irri- 


172  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

lability  of  temper,  restlessness,  and  possibly  a  slight  disturbance 
of  the  alimentary  tract.  Even  the  latter  is  by  no  means  a  neces- 
sary consequence.  The  gastro-intestinal  tract  is  more  predisposed 
to  fermentative  diarrheas  during  dentition,  but  these  are  not 
primarily  caused  by  teething,  but  by  infection  from  without,  the 
intestinal  tract  being  in  a  more  irritable  condition  at  this  time,  and 
therefore  less  resistant  to  external  sources  of  infection. 

One  of  the  complications  of  dentition  most  dreaded  by 
mothers  are  convulsions.  Leaving  out  of  the  question  those 
children  with  neurotic  histories  or  those  whose  constitutions  have 
been  weakened  by  inherited  syphilis,  rachitis,  or  tuberculosis,  we 
can  not  now  recall  a  single  case  in  which  teething  has  primarily 
caused  convulsions.  In  the  majority  of  patients  who  have  come 
under  our  notice  with  convulsions  during  dentition  the  cause 
could  almost  invariably  be  traced  to  an  attack  of  acute  indiges- 
tion in  a  child  whose  digestive  apparatus  was  in  a  hypersensitive 
state  at  this  particular  time ;  the  primary  cause,  however,  has 
been  a  badly  regulated  diet,  and  not  the  cutting  of  the  tooth. 
Bronchitis  and  bronchopneumonia  have  also  been  ascribed  to 
dentition.  It  is  true  that  a  slight  irritation  of  the  faucial  or 
nasal  mucous  membrane  may,  in  a  sensitive  child,  be  >produced 
by  sympathetic  irritation ;  but  here  again  we  must  say  that 
we  have  never  seen  a  case  of  either  of  the  before-mentioned 
diseases  arise  from  dentition.  A  slight  erythematous  rash,  for- 
merly known  as  tooth-rash  and  still  associated  with  dentition 
in  the  minds  of  parents,  sometimes  covers  the  body  at  various 
intervals  during  this  period,  but  as  children  affected  by  it  have 
always  at  the  same  time  had  gastro-intestinal  disorders,  we  can 
not  believe  that  dentition  was  responsible  for  the  cutaneous  affec- 
tion. In  children  affected  by  struma  or  in  rachitic  babies  it  is 
not  uncommon  to  find  enlargement  of  the  glands  of  the  neck  or- 
some  irritation  of  the  ears. 

Ordinarily  a  healthy  child  will  evince  no  symptoms  severe 
enough  to  demand  any  special  treatment.  When,  however,  an 
infant  is  feverish,  restless,  and  irritable,  it  is  proper  that  the  phy- 
sician endeavor  to  quiet  this  condition  by  suitable  medicinal 
means.  Small  repeated  doses  of  bromids  with  camphor  water, 
or,  what  we  have  found  more  useful,  small  doses  of  antipyrin, 
will  generally  bring  about  this  result.  A  prescription  which  we 
have  frequently  employed  is  as  follows : 

R.   Sodii  bromid., gr.  ij 

Antipyrin, gr.  i-ij 

Glycerin., TTLiij 

Spirit,  menthae  piperitoe, gtt.  ss-j 

Aqua  camph.  (or  soda-mint  mixture),  ...        .    £j. 

SlG. — To  be  repeated  every  two  or  three  hours  until  the  child  is  quieted. 


ESOPHAGITIS.  173 

During  the  period  of  dentition  the  child's  diet  should  receive 
the  strictest  care,  as  it  is  at  this  time  that  the  most  virulent  forms 
of  intestinal  diseases  frequently  make  their  appearance.  The 
"  second  summer,"  which  is  looked  upon  with  so  much  dread  by 
mothers,  is  frequently  coincident  with  the  period  of  active  denti- 
tion, and  it  must  be  borne  in  mind  that  at  this  time  the  nervous 
system  is  generally  in  a  more  or  less  hypersensitive  condition, 
and  therefore  the  digestive  system,  sharing  in  this  irritability,  is 
less  able  to  combat  the  attacks  made  on  it  by  external  causes  of 
infection.  Children  whose  systems  are  enfeebled  from  constitu- 
tional diseases  should  be  appropriately  treated,  and  rachitic  or 
strumous  patients,  who  are  apt  to  be  especially  depressed  at  this 
time  and  are  always  slow  in  cutting  their  teeth,  should  be  treated 
by  the  administration  of  oils  and  such  remedies  as  phosphorus 
and  the  salts  of  calcium  and  general  tonics.  When  a  tooth  is 
slow  in  coming  through  the  gum  and  its  eruption  is  accompanied 
by  a  decided  and  continued  rise  of  temperature  or  severe  nervous 
symptoms,  lancing  the  gum  is  often  beneficial.  Unless  the  phy- 
sician has  a  clear  idea  of  the  exact  position  of  the  tooth  which  is 
causing  the  trouble,  gum-lancing  is  of  very  little  use  and  simply 
produces  an  open  wound,  which  always  offers  an  entrance-point 
for  infective  germs.  The  custom  of  indiscriminate  gum-lancing 
is  to  be  condemned. 


DISEASES  OF  THE  ESOPHAGUS. 

ESOPHAGITIS. 

Inflammations  of  the  esophagus  are  of  rare  occurrence  in  chil- 
dren. It  is  stated  that  inflammations  of  the  mouth,  although 
very  common,  extend  but  rarely  into  the  esophagus. 

ACUTE  ESOPHAGITIS. 

Inflammation  of  the  esophagus  may  be  caused  by  lacerations 
produced  by  swallowing  a  foreign  body  or  by  corrosive  poisons. 
Either  of  these  causes  may  involve  the  mucous  membrane  or  may 
extend  into  the  muscular  coat.  The  latter  is,  however,  of  rare 
occurrence.  When  a  foreign  body  has  been  swallowed,  the  early 
symptoms  are  pain  or  swelling  and  a  general  discomfort  in 
the  region.  When  strong  acids  or  caustic  alkalies  have  been 
taken  into  the  mouth,  the  mucous  membrane  of  the  latter  will  be 
inflamed  and  ulcerated,  the  character  of  both  varying  somewhat 
with  the  poison  taken.  There  will  be  a  burning  pain  in  all  the 


DISEASES    OF    THE    DIGESTIVE    ORGANS. 

parts  affected,  great  thirst,  and  a  spasm  of  the  esophagus  follow- 
ing attempts  at  swallowing.  Deglutition  is  almost  impossible. 
The  period  of  acute  inflammation  will  last  several  days,  and  dur- 
ing this  time  there  is  often  great  danger  of  suffocation  from 
edema  of  the  glottis.  Later,  symptoms  of  stricture  are  very 
common,  these  usually  occurring  in  from  three  to  six  months 
after  the  injury. 

Treatment. — The  indications  for  treatment  are  to  remove  the 
foreign  body,  and  when  the  inflammation  is  produced  by  poisons, 
to  neutralize  the  latter  as  quickly  as  possible  by  the  use  of  oils, 
demulcent  drinks,  and  ice.  For  the  pain,  opium  is  indicated. 
The  treatment  of  stricture  of  the  esophagus  is  surgical. 


DISEASES    OF   THE    STOMACH. 

GASTRITIS. 

Synonyms. — ACUTE  GASTRIC  CATARRH  ;  ACUTE  DYSPEPSIA  ;  GAS- 
TRIC FEVER  ;  GASTRO-ADENITIS. 

Varieties. — Acute  gastritis  ;  chronic  gastritis  ;  ulcerative  gas- 
tritis ;  gastromalacia. 

Acute  gastritis  is  an  acute  inflammation  of  the  glandular  tis- 
sue of  the  stomach,  interfering  with  the  digestive  functions,  and 
generally  due  to  the  presence  of  irritating  ingesta  (Blackader). 

Causes. — By  far  the  most  frequent  cause  is  food  improper  in 
kind,  quantity,  preparation,  or  time  of  use.  Although  acute  gastri- 
tis rarely  occurs  in  young  children  fed  on  breast  milk,  yet  it  is  oc- 
casionally seen.  In  most  cases  the  attack  can  be  traced  to  some 
morsel  of  coarse  "table  food,"  candy,  or  cakes.  The  substitu- 
tion of  artificial  feeding  in  nurslings,  especially  when  the  food 
is  improperly  prepared,  is  another  frequent  and  powerful  cause. 
Unsterilized  water  often  produces  acute  dyspepsia.  An  attack 
of  acute  gastritis  sometimes  precedes  the  eruption  of  a  tooth, 
although  in  many  instances  it  is  hard  to  prove  whether  the  attack 
is  due  primarily  to  disordered  dentition  or  to  some  error  in  diet 
during  this  epoch  when  the  whole  digestive  tract  is  in  a  more  or 
less  irritable  state. 

In  older  children  large  quantities  of  food  taken  at  one  time, 
late  meals,  highly  spiced  articles,  too  great  a  variety  of  food, 
and  very  rapid  eating  are  the  most  common  causes.  Children  born 
with  an  enfeebled  nervous  system  and  those  reared  on  pro- 


GASTRITIS.  1/5 

prietary  foods  are  particularly  liable  to  gastritis.  Sudden  chill- 
ing of  the  skin  has  been  shown  to  be  an  occasional  cause. 

Symptoms. — At  the  onset  of  an  attack  of  gastritis  a  child 
who  has  previously  been  reasonably  healthy  loses  interest  in  its 
play  and  surroundings.  If  asleep,  it  may  awake  crying  and  com- 
plaining of  pain,  usually  referred  to  the  abdomen.  In  young 
children  the  thighs  are  then  flexed  on  the  abdomen  and  the  legs 
on  the  thighs  ;  the  arms  also  are  flexed.  The  crying  is  sharp, 
shrill,  and  continuous,  and  around  the  mouth  and  chin  there  is 
generally  a  pale-blue  line.  In  the  febrile  type  the  temperature  may 
rise  to  102°  to  103°  F.  (38.9°  to  39.4°  C).  The  pulse  and 
respiration  are  both  accelerated.  Vomiting  is  an  almost  constant 
symptom,  accompanied  by  nausea  and  full  unloading  or  retching  ; 
this  vomiting  must  never  be  mistaken  for  the  simple  regurgitation 
of  milk  which  occurs  when  the  infant  has  taken  more  than  the 
stomach  can  hold. 

Upon  examination  of  the  vomited  matter  hydrochloric  acid 
will  be  found  to  be  deficient.  The  emesis  may  continue  for  a 
considerable  time  after  the  contents  of  the  stomach  have  been 
evacuated.  The  tongue  is  usually  covered  with  a  white  or 
brownish-white  coat ;  this  coating  is  particularly  heavy  at  the 
base  of  the  tongue,  while  the  tip  and  edges  of  the  latter  are  a 
bright  red.  There  is  complete  loss  of  appetite,  and  when  the 
intestines  become  involved  (as  they  nearly  always  are  to  some 
extent),  there  will  be  diarrhea,  with  the  expulsion,  first,  of  the 
normal  contents  of  the  bowels,  and,  later,  large  quantities  of 
mucus.  Occasionally  the  attack  is  ushered  in  by  convulsions, 
which  are  sometimes  quite  severe,  and  one  of  the  authors  re- 
members a  child  five  years  of  age  who,  forty-eight  hours  after 
having  eaten  a  large  variety  of  cakes  and  candy,  was  taken  with 
violent  convulsions  of  an  eclamptic  character.  Unconsciousness 
was  to  all  appearances  profound  ;  the  temperature  and  pulse  were 
both  considerably  above  normal,  and  the  type  of  spasm  was  first 
tonic,  followed  by  a  long-continued  series  of  clonic  movements. 
The  symptoms  rapidly  disappeared  after  thorough  evacuation  of 
the  stomach  and  bowels,  wrapping  the  child  in  a  hot  wet-pack, 
and  stimulation  of  the  rapidly  failing  heart  by  hypodermic  injec- 
tions of  strychnin  and  atropin. 

Other  symptoms  of  acute  gastritis  which  are  noticed  particu- 
larly in  older  children  are  :  Tenderness  in  the  epigastrium,  with  a 
moderate  distention  of  the  abdomen,  often  causing  pain  or  uneasi- 
ness on  the  slightest  touch  ;  headache,  which  may  be  general  or 
confined  to  the  frontal  or  occipital  regions  ;  occasionally  pharyn- 
gitis may  appear.  Phenomena  simulating  profound  nervous 


DISEASES    OF    THE    DIGESTIVE    ORGANS. 

disturbance  may  occasionally  be  met ;  thus,  Seibert  has  reported 
a  number  of  cases  in  which  the  symptoms  of  gastritis  closely 
resembled  those  of  cerebral  meningitis,  and  instances  in  which 
aphasia  and  hemiplegia  followed  the  eating  of  a  large  amount  of 
indigestible  food  are  reported  by  Henoch,  Fraenkel,  and  others. 
When  the  inflammation  extends  as  far  as  the  duodenum,  an 
attack  of  catarrhal  jaundice  may  follow  within  a  day  or  two.  If 
the  attack  is  not  very  severe,  the  symptoms  will  subside  rapidly 
in  from  one  to  three  days.  When  severe  or  when  the  cause  is 
not  quickly  removed,  the  stomach  may  remain  inflamed  for  sev- 
eral days,  the  gastric  irritation  being  accompanied  by  fever  and 
evidences  of  rather  severe  exhaustion. 

Pathology. — The  mucous  membrane  of  the  stomach  appears 
swollen  and  reddened.  In  severe  attacks  erosions  and  even 
slight  hemorrhages  may  be  found.  The  tissue  beneath  the 
mucous  membrane — the  submucosa — will  be  found  edematous  ; 
when  seen  through  a  microscope,  the  interstitial  tissue  is  infil- 
trated with  leukocytes,  and  the  differentiation  between  the  parietal 
and  principal  cells  can  not  be  made  out.  All  the  cells  appear 
cloudy  and  granular  and  partially  separated  from  the  membrana 
propria  of  the  gland.  There  is  a  great  abundance  of  .the  mucous 
cells  in  the  pyloric  region,  and  this  increase  extends  deeply  into 
the  ducts  of  the  gland. 

Prognosis. — The  prognosis  of  acute  gastritis  is  good,  except 
when  the  child  has  for  a  long  time  been  badly  nourished.  It  is 
less  favorable  in  bottle-fed  babies  and  in  older  children  when  the 
attack  is  complicated  by  severe  convulsions.  If  nephritis  is  coex- 
istent, or  when  the  attack  occurs  at  the  end  of  one  of  the  con- 
tinued fevers,  the  outlook  is  not  so  good. 

Treatment. — In  an  attack  of  acute  indigestion  the  first  indi- 
cation is  to  remove  the  irritating  material  as  quickly  as  possible. 
With  this  object  in  view  the  vomiting  should  not  be  checked 
unless  it  produces  severe  exhaustion.  Indeed,  very  frequently  it 
is  well  to  aid  the  expulsion  of  undigested  food  by  the  adminis- 
tration of  emetics,  such  as  weak  mustard-water  or  ipecac.  Ipecac 
is  best  given  in  the  form  of  syrup  or  wine,  in  teaspoonful  doses, 
repeated  until  vomiting  occurs.  In  some  cases  it  will  be  neces- 
sary to  wash  out  the  stomach  by  means  of  a  stomach-tube.  The 
bowels  should  be  evacuated  thoroughly  by  means  of  some  mild 
purgative,  and  probably  for  this  purpose  there  is  no  drug  so  use- 
ful as  calomel.  It  has  been  our  experience  that  this  agent  can 
be  given  with  much  better  effect  in  small  doses  repeated  at  short 
intervals  until  the  desired  action  is  obtained.  A  useful  formula 
is  the  following : 


GASTRITIS.  177 

R .     Hydrarg.  chlorid.  mite, gr.  iij 

Pulv.    ipecac., _ gr.  vj 

Sodii  bicarb., £  ij. 

M.  et  div.  chart.  No.  xxx. 

SlG. — One  powder  every  hour  until  the  stools  change  to  normal  color. 

It  is  often  good  practice,  after  having  used  these  powders  for 
twelve  hours,  to  administer  a  dram  or  two  of  castor  oil.  Young 
children  often  take  this  agent  remarkably  well ;  when,  however, 
the  child  objects  to  taking  it,  the  oil  may  be  sandwiched  between 
two  thin  layers  of  some  tart  jelly,  or  it  may  be  given  with  a  few 
drops  of  whisky,  or  floating  on  iced  water.  In  older  children  any 
of  the  formulas  given  below  may  be  found  useful : 

R  .    Hydrarg.  chlorid.  mite,       gr.  ii-v 

Sodii  bicarb., gr.  xii-xxx. 

M.  et  div.  chart.  No.  viii. 

SlG. — One  powder  every  two  hours  until  the  bowels  are  freely  evacuated. 
For  a  child  from  two  to  four  years  old. 

R .     Sodii  et  potassii  tartratis, gr.  xx-xl 

Sodii  bicarb., gr.  iii-vj. 

M.  et  div.  chart.  No.  vi. 
SlG. — One  powder  to  be  given  in  a  wineglassful  of  hot  water  every  hour 

or  two  until  the  bowels  are  freely  evacuated. 

R .     Hydrarg.  cum  creta, gr.  vi-viij 

Sodii  bicarb. , gr.  viii-x 

Pulv.  rhei  comp., gr.  xij. 

M.  et  div.  chart.  No.  iv. 
SlG. — One  to  be  given  every  two  hours  until  the  bowels  are  emptied. 

The  intestinal  antiseptics,  such  as  salol,  beta-naphthol,  and 
naphthalene,  given  in  doses  suitable  for  the  age  of  the  child,  are 
very  useful.  Beta-naphthol  bismuth,  in  doses  of  from  one  to 
five  grains,  according  to  the  age  of  the  child,  and  repeated  every 
three  or  four  hours,  has  given  good  results.  When  the  vomit- 
ing is  persistent,  minute  doses  of  calomel  mixed  with  bicarbonate 
of  soda  or  triturated  with  sugar  of  milk  are  very  beneficial. 
Small  doses  of  y1^-  of  a  grain  of  calomel  combined  with  from 
TUT  to  TTU"  °f  a  Sram  °f  arsenite  of  copper  have,  in  our  expe- 
rience, worked  admirably  in  checking  several  cases  of  severe 
vomiting.  When  the  vomiting  continues  for  some  time  after  the 
stomach  is  empty  or  immediately  follows  the  taking  of  food, 
from  one  to  five  drops  of  tincture  of  nux  vomica,  given  just 
before  feeding,  will  often  stop  further  trouble.  Small  doses  of 
sulphate  of  magnesium  have  been  recommended  by  Stuart 
Patterson  in  the  treatment  of  this  condition.  When  the  attack 
involves  the  intestines,  the  accompanying  diarrhea  is  best  treated 
by  rectal  injections  of  a  pint  or  a  pint  and  a  half  of  cool  sterilized 


1/8  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

water  containing  one  of  the  intestinal  antiseptics.    A  useful  formula 
is  the  following : 

R.     Bismuth,  subnit., 
Salol, 

Sodii  bicarb., t aa  gr.  v. 

M.  SIG. — The  entire  powder  to  be  used  at  an  injection.  These  should  be 
repeated  from  one  to  three  times  a  day,  according  to  the  severity  of  the 
case. 

Injections  into  the  bowel  of  a  sterilized  i  per  cent,  solution  of 
chlorid  of  sodium  are  particularly  useful,  and  can  be  relied  on  for 
most  cases.  Of  the  greatest  importance  in  acute  gastritis  is  the 
regulation  of  the  diet ;  during  the  attack  the  stomach  should  be 
allowed  absolute  rest,  no  food  being  given.  In  bottle-fed  babies, 
particularly  during  the  summer  months,  milk  and  all  articles  con- 
taining milk  should  be  omitted.  For  the  first  twenty-four  to 
thirty-six  hours  the  infant  should  receive  nothing  but  cold  steril- 
ized water  in  quantities  of  from  half  an  ounce  to  an  ounce  every 
three  or  four  hours,  slowly  administered.  This  water  may  con- 
tain about  twenty  or  thirty  drops  of  good  whisky  or  brandy. 
When  the  vomiting  and  diarrhea  have  ceased,  the  child  may  receive 
small  quantities  of  some  good  beef-extract  or  thin,  str.ained  broth. 
Barley-water  or  rice-water  may  also  be  allowed  in  small  portions. 
When  meat  extracts  can  not  be  borne  by  the  stomach,  albumin 
water,  made  by  mixing  the  whites  of  two  fresh  eggs  in  a  glass  of 
water  and  having  in  it  a  little  salt,  will  sometimes  do  very  well, 
and  occasionally  koumiss  is  well  retained  by  older  children.  For 
the  latter  the  diet  should  consist  of  thin  broths,  and  when  the  in- 
testines are  not  involve.d,  small  quantities  of  starchy  foods  may 
be  allowed.  When  fever  is  present,  the  child  should  be  occasion- 
ally sponged  with  cool  water  containing  alcohol  or  ammonia. 
The  customary  diet  of  the  child  should  be  resumed  by  degrees. 
Many  children  recover  much  faster  if  they  are  sent  to  the  coun- 
try, or  particularly  to  the  seashore.  Frequently  even  the 
change  of  a  visit  to  the  house  of  some  relative  near  by  will  prove 
beneficial. 

CHRONIC  GASTRITIS. 
Synonyms. — CHRONIC  GLANDULAR  GASTRITIS  ;  CHRONIC  VOMITING. 

This  disease  consists  in  a  chronic  inflammation  of  the  mucous 
membrane  lining  the  stomach,  attended  by  hyperemia  and  thick- 
ening of  the  mucosa,  giving  rise  to  a  decrease  both  in  the 
quantity  and  quality  of  the  true  glandular  secretion  of  the 
stomach,  the  gastric  juice.  As  a  result  of  the  chronic  catarrh 


CHRONIC    GASTRITIS.  179 

large  quantities  of  adherent  mucus  of  a  strongly  alkaline  reaction 
are  formed.  This  results  in  an  enfeeblement  of  the  digestive 
powers  of  the  stomach,  which,  in  turn,  frequently  causes  reten- 
tion of  food  and  consequent  fermentation. 

Varieties. — Chronic  infantile  gastric  catarrh  ;  chronic  gastro- 
enteritis. 

Causes. — A  very  common  cause  is  the  continuation  of  an  attack 
of  acute  gastric  catarrh,  the  treatment  of  which  has  been 
neglected.  The  too  hasty  mastication  of  food,  eating  at  too 
frequent  intervals,  a  diet  unsuitable  for  the  child,  such  as  very 
rich,  improperly  cooked,  or  highly  seasoned  foods  ;  the  continued 
used  of  candy,  cakes,  fried  foods,  or  hot  breads  ;  general  bad 
hygiene,  uncleanliness,  and  the  constant  use  of  starchy  foods  or 
those  containing  too  large  an  amount  of  sugar  are  frequent 
causes  of  chronic  gastritis  in  infants.  As  predisposing  causes  we 
have  syphilis,  rachitis,  scrofula,  and  a  low  degree  of  inherent 
vitality.  Diseases  of  the  heart,  lungs,  liver,  and  kidneys  may  also 
act  as  predisposing  causes. 

The  repeated  swallowing  of  infected  discharges  from  ulcera- 
tions  in  the  mouth,  throat,  or  nose,  or  the  mucus  from  chronic 
nasopharyngeal  catarrh,  and  carious  teeth  may  also  act  as 
causes. 

Pathology. — The  pathologic  changes  in  chronic  gastritis  are 
of  the  same  nature  as  those  in  the  acute  form.  The  mucous 
membrane  becomes  thicker  as  the  disease  progresses,  its  color 
turns  grayish,  with  deeply  injected  areas.  The  whole  membrane 
is  covered  with  patches  of  dense,  sticky  mucus.  Throughout 
the  whole  mucosa,  but  particularly  in  the  region  of  the  pylorus, 
we  find  small  papillary  projections,  caused  by  the  hypertrophy  of 
the  mucous  membrane.  This  condition  is  sometimes  known  as 
etat  mamellone,  and  may,  in  very  bad  cases,  advance  to  such  an 
extent  as  to  produce  absolute  polypoid  growth.  The  gland-cells 
may  be  destroyed  in  patches,  rendering  the  differentiation  between 
the  principal  and  parietal  cells  impossible.  If  the  disease  pro- 
gresses, an  infiltration  of  small  cells  takes  place,  with  loosening 
and  separation  of  the  superficial  layer  of  the  epithelium.  Accord- 
ing to  Ewald,  there  is  a  mucoid  transformation  of  the  cells  of  the 
tubules,  which  may  extend  to  the  base  of  the  gland.  In  very 
advanced  cases  there  is  a  progressive  fatty  degeneration  of  the 
cells,  finally  ending  in  an  acute  atrophy  of  the  mucous  membrane. 

Symptoms. — The  attack  is  usually  a  simple  continuation  of 
the  symptoms  of  acute  gastritis.  The  vomiting  at  first  is  of  the 
contents  of  the  stomach,  then  of  sour,  bile-stained  mucus,  and, 
finally,  when  this  symptom  continues,  there  will  be  simply  an 


I  SO  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

ejection  of  clear,  watery  fluid,  sour  smelling  and  tasting,  fre- 
quently mixed  with  fragments  of  food.  Vomiting  is  increased 
after  the  taking  of  food,  and  in  young  infants  particularly  after 
the  ingestion  of  farinaceous  foods.  Vague  feelings  of  distress 
and  pain  are  felt,  referred  to  the  abdomen,  the  infant  generally 
lying  with  its  legs  drawn  up.  The  abdomen  itself  is  usually  dis- 
tended and  distinctly  tender  to  the  touch.  As  a  general  rule  the 
bowels  are  constipated,  although  there  may  be  occasional  short 
attacks  of  diarrhea,  during  which  considerable  quantities  of  mucus 
are  passed.  Eructations  of  gas  are  common,  particularly  after 
feeding.  The  tongue  is  coated,  this  coating  being  greatest  at  the 
back  and  center  of  the  organ.  The  papillae  are  enlarged  and  the 
edges  and  tip  are  of  a  bright  glazed  red. 

The  skin  in  children  suffering  from  chronic  gastritis  is  dry  and 
scurfy  ;  this  symptom  is  particularly  noticeable  on  the  surface  of 
the  scalp.  Various  irregular  forms  of  skin  eruptions  may  appear. 
Several  of  the  forms  of  stomatitis  are  not  rare,  the  parasitic 
variety  being  that  most  commonly  met.  The  general  condition 
of  these  patients  is  poor,  and  their  appearance  is  that  of  chronic 
ill  health.  They  are  thin,  pale,  with  sunken  eyes,  depressed 
fontanels,  and,  when  the  disease  is  prolonged,  show  the  character- 
istic angular  face  of  marasmus.  Under  the  eyes  and  around  the 
mouth  will  be  seen  the  blue  line  so  common  in  chronic  affections 
of  the  digestive  organs.  The  appetite  is  generally  poor,  although 
it  is  not  at  all  uncommon  for  a  child  who  has  refused  food  when 
offered  at  the  proper  times  to  ask  eagerly  for  all  sorts  of  odd  arti- 
cles of  diet  between  meals  and  at  night.  These  children  sleep 
poorly  ;  at  night  they  are  often  disturbed  by  frightful  dreams, 
from  which  they  start  wildly  and  cry  out ;  incontinence  of  urine  is 
very  common.  Frontal  headache  is  a  frequent  symptom,  and 
choreic  movements  not  seldom  occur.  Otitis  media  and  abscess 
of  the  middle  ear  may  occur.  Cases  of  apparent  loss  of  con- 
sciousness and  symptoms  resembling  petit  mal  due  to  chronic 
gastritis  have  been  reported.  Attacks  of  irregular  heart  action 
are  very  frequently  met,  but  this  symptom  appears  chiefly  in 
older  children.  These  children  seem  to  be  continually  deficient 
in  bodily  heat,  have  cold  feet  and  hands,  which,  unless  they  are 
continually  surrounded  by  external  warmth,  feel  to  them  icy 
cold.  From  various  reflex  irritations  we  may  have  a  dry,  hack- 
ing, or,  as  is  occasionally  heard,  a  loud,  ringing  cough,  somewhat 
paroxysmal  in  character  and  increased  at  night  or  after  taking 
some  article  of  indigestible  food.  Various  intestinal  irritations 
simulating  worms  may  also  be  present.  Occasionally  a  slight 
rise  of  temperature  is  noticed  in  the  afternoons. 


p«if/c  cou 

CHRONIC    GASTRITIS.  iSl 

Diagnosis. — The  diagnosis  is  founded  on  the  long  continu- 
ance of  the  disease,  the  chronically  disturbed  digestion,  bad 
nutrition,  and  the  exclusion  of  organic  diseases  of  the  heart, 
lungs,  and  kidney.  The  disease  with  which  it  is  most  likely  to 
be  confounded  is  tuberculosis,  especially  when  the  latter  has 
reached  an  advanced  stage  ;  but  in  tuberculosis  we  have  involve- 
ment of  the  lungs,  and  a  greater  and  more  constant  rise  of  tem- 
perature. The  abdomen,  too,  of  a  tuberculous  patient  is  apt  to 
be  sunken  ;  the  finding  of  the  bacillus  tuberculosis  in  any  of  the 
discharges  would  settle  the  diagnosis. 

From  syphilis  it  can  be  differentiated  by  the  fact  that  in  spe- 
cific disease  we  have  the  characteristic  eruptions  and  many  other 
symptoms  of  this  affection.  In  any  doubtful  case  the  application 
of  antisyphilitic  remedies  may  settle  the  question  of  the  diagno- 
sis. Typhoid  fever  can  be  differentiated  by  the  character  of  the 
stools  in  the  latter  disease,  the  fact  that  young  infants  are  not 
very  susceptible  to  typhoid  fever,  the  characteristic-  temperature 
range,  and  the  greater  severity  of  the  attack.  Widal's  blood  test 
will  conclusively  prove  the  diagnosis  of  typhoid  fever. 

Prognosis. — Under  proper  diet,  care,  and  hygienic  surround- 
ings the  outlook  for  children  affected  with  chronic  gastritis  is 
fairly  good.  The  prognosis  is  rather  worse  during  the  teething 
period,  particularly  if  this  occurs  during  the  summer  months.  It 
should  not  be  forgotten  that  while  chronic  inflammation  of  the 
stomach  is  not  often  fatal  itself,  yet  it  so  lowers  the  vitality  of  the 
child  as  to  render  it  an  easy  prey  to  other  diseases. 

Treatment. — The  first  indication  of  treatment  is  carefully  to 
regulate  the  diet,  feeding  the  child  at  as  regular  intervals  as  pos- 
sible, and  far  enough  apart  to  give  the  stomach  a  period  of  abso- 
lute rest  between  them.  Of  scarcely  less  importance  are  the  gen- 
eral hygienic  surroundings  of  the  child,  its  bath,  clothing,  and 
general  mode  of  life.  In  selecting  a  diet  for  these  cases  we  must 
pick  out  one  which  will  adapt  itself  to  the  portion  of  the  digestive 
tract  which  is  the  healthiest.  Infants  who  have  been  fed  on  farina- 
ceous foods  or  condensed  milk,  those  who  have  nursed  from 
the  breast  of  an  unhealthy  mother,  or  who  have  been  given  the 
breast  at  irregular  intervals,  so  that  their  stomachs  are  kept  in  a 
continually  overloaded  condition,  should  have  their  diet  strictly 
regulated.  Infants  who  have  been  fed  on  artificial  foods  should 
be  placed  on  a  diet  of  modified  milk,  the  formula  of  which  may 
have  to  be  changed  many  times  ;  or,  if  that  disagrees,  they  should 
be  fed  on  small  and  carefully  regulated  quantities  of  animal  broths 
or  extracts  or  predigested  milk.  Breast-fed  babies  should  be 
nursed  at  exact  intervals  of  from  two  and  one-half  to  three  hours, 


1 82  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

and  between  these  periods  no  food  whatever  should  be  given. 
In  older  children  a  carefully  prepared  bill  of  fare  should  be 
directed  by  the  physician  each  day.  This  diet-list  (best  written 
down)  should  carefully  avoid  all  rich  or  highly  seasoned  foods 
or  a  great  variety,  although  a  certain  amount  of  change  in  diet  is 
as  important  to  a  child  as  it  is  to  an  adult.  The  particular  kind 
of  food  must  be  selected  by  the  physician  for  each  individual 
case,  for  it  is  impossible  to  give  definite  rules  as  to  the  diet 
proper  for  these  children.  It  is  of  importance,  however,  that  the 
heaviest  meal  should  be  given  in  the  middle  of  the  day,  and  that  a 
very  light  supper,  consisting  of  crackers  and  warm  milk  or  a 
small  quantity  of  thin  strained  broth,  should  be  eaten  at  night. 
The  last  meal  should  be  taken  not  less  than  an  hour  before  retir- 
ing. For  more  careful  directions  as  to  the  feeding  of  these 
children  the  reader  is  referred  to  the  chapter  on  the  preparation 
of  foods.  These  patients  should  be  kept  as  much  as  possible  in 
the  open  air ;  although  they  do  well  in  the  country,  yet  the  sea- 
shore is  decidedly  the  best  place  for  them.  It  is  of  considerable 
importance  in  selecting  a  place  for  their  convalescence  that  one 
be  chosen  where  the  drainage  is  at  least  fairly  good.  On  account 
of  the  hyperesthetic  nervous  condition  which  almost  always 
accompanies  chronic  digestive  diseases  of  all  kinds,  these  patients 
should  be  kept  as  much  as  possible  from  frights  and  nervous 
shocks.  They  should  not  be  put  to  school  too  early,  or  sub- 
jected to  the  long-continued  hours  of  study  which  children 
usually  have  to  undergo.  The  daily  bath  is  a  matter  of  con- 
siderable importance.  Each  night  and  morning  the  patient 
should  be  sponged  off  with  water  at  a  temperature  of  about  86° 
F.  (30°  C).  Sponge-baths  of  sea-water  or  water  containing 
rock-salt  are  of  great  value.  Wiederhofer  recommends  that  as 
soon  as  a  child  is  out  of  bed  in  the  morning  it  should  receive  a 
good  rubbing  with  a  rough  towel.  It  should  then  stand  in  the 
bath,  which  contains  warm  water  three  or  four  inches  in  depth, 
and  be  sponged  down  as  quickly  as  possible  with  cool  salt  water, 
and  a  half  a  gallon  of  the  same  be  emptied  over  the  chest  and 
shoulders.  The  child  should  again  be  rubbed  dry  until  the 
skin  is  well  reddened.  Long  hours  of  sleep  are  of  the  utmost 
importance  to  these  patients.  Massage  of  the  abdomen  and  the 
application  of  faradic  electricity  are  extremely  useful  adjuncts  in 
the  treatment. 

The  indications  for  medicinal  treatment  are,  first,  to  rid,  as  far 
as  possible,  the  mucous  membrane  of  the  adherent  mucus  which 
covers  it,  and  then  to  stimulate  it  to  a  secretion  of  healthy  gastric 
juice.  In  order  to  accomplish  the  former  the  practice  of  wash- 


CYCLIC    VOMITING.  183 

ing  out  the  stomach  by  means  of  a  stomach-tube  and  funnel  is 
of  the  greatest  use,  and  should  be  repeated  three  or  four  times 
a  week.  When  this  can  not  be  borne,  as  in  cases  in  which 
it  excites  persistent  vomiting  or  when  organic,  cardiac,  or  pul- 
monary disease  exists,  lavage  may  be  substituted  by  warm 
alkaline  drinks  or  small  quantities  of  alkaline  mineral  water. 
Calomel  in  these  cases  is  a  remedy  of  great  usefulness  ;  small 
doses  may  be  given  in  combination  with  bicarbonate  of  soda. 
Potassiotartrate  of  soda,  or  phosphate  of  soda,  given  three  or  four, 
times  a  day  has  peculiar  tonic  value.  When  diarrhea  occurs,  cal- 
omel with  salol  or  beta-naphthol  bismuth  may  be  used.  In  some 
cases  the  sulphate  of  magnesia  is  highly  recommended  to  relieve 
the  constipation  of  this  disease,  and  an  occasional  single  dose  of 
castor  oil  acts  happily  to  cleanse  the  whole  intestine.  Hydro- 
chloric and  nitrohydrochloric  acid  in  doses  suitable  to  the  age  of 
the  child  are  very  useful  agents.  The  various  bitter  tonics,  such 
as  nux  vomica,  gentian,  or  quassia,  are  valuable  in  these  cases. 

CYCLIC  VOMITING. 

Cyclic  vomiting  is  a  condition  occurring  most  often  in  children 
of  gouty  or  neurotic  tendencies,  and  is  characterized  by  periodic 
and  recurring  attacks  of  severe  vomiting.  The  attack  does 
not  necessarily  follow  acute  indigestion,  but  is  accompanied  by 
deficient  excretion  of  uric  acid  and  followed  by  severe  prostra- 
tion, from  which  the  patient  rapidly  recovers. 

Causes. — The  direct  exciting  cause  has  not  been  discovered, 
but  it  seems  to  be  associated  with  a  general  derangement  of  nu- 
trition and  assimilation.  At  the  present  time  it  is  commonly 
classed  as  a  gastric  neurosis  allied  to  migraine.  Exhaustion, 
fatigue,  overstudy,  or  overwork  seem  to  act  as  predisposing  causes. 

The  attacks,  which  recur  at  intervals  varying  from  a  week 
to  several  months,  are  usually  preceded  by  a  prodromal  stage 
lasting  from  twelve  to  twenty-four  hours.  During  this  period 
the  child  will  be  languid  and  dull,  with  loss  of  appetite,  occa- 
sionally constipation,  and  a  sense  of  general  discomfort  in  the 
epigastrium.  The  temperature  is  usually  elevated,  and  in  Holt's 
cases  reached  103°  F.  (39.4°  C).  The  excretion  of  uric  acid  is 
considerably  under  normal.  At  the  end  of  the  prodromal  stage 
the  child  is  suddenly  seized  with  vomiting,  at  first  after  taking 
food  or  drink,  but  soon  the  vomiting  becomes  almost  constant, 
or  in  some  cases  there  may  be  an  interval  of  a  half  hour  or  so  ; 
it  is  accompanied  by  great  retching  and  distress.  The  vomited 
matter  consists  of  frothy  mucus  and  serum,  which  may  occa- 


184  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

sionally  be  blood-streaked.  The  reaction  is  highly  acid.  After 
the  beginning  of  the  vomiting  the  temperature  falls  considerably. 
From  the  severe  vomiting  the  child  becomes  exhausted  to  a 
degree  which  may  excite  alarm  ;  the  pulse  is  rapid,  weak,  and 
sometimes  irregular.  No  distention  of  the  abdomen  usually  ex- 
ists. As  the  attack  draws  to  a  close  the  vomiting  becomes  less 
frequent  and  severe  and  the  patient  gradually  recovers — indeed, 
at  the  end  of  the  period  the  child  is  often  better  than  before  the 
attack  began. 

Diagnosis.— —Cyclic  vomiting  may  be  differentiated  from  acute 
indigestion  by  the  fact  that  in  cyclic  vomiting  the  attacks  are  not 
brought  on  by  indigestible  food  and  by  the  persistence  of  the 
vomiting.  From  gastritis  it  can  be  distinguished  by  its  short 
duration  and  self-limited  course.  The  diagnosis  between  cyclic 
vomiting  and  that  of  organic  disease  of  the  kidneys  must  be 
founded  on  a  careful  study  of  the  urine.  Meningitis  should  be 
differentiated  by  the  fact  that  the  general  history  of  the  two  dis- 
eases differs.  In  cyclic  vomiting  there  is  a  history  of  repeated 
attacks  occurring  over  a  considerable  period  of  time. 

Treatment. — When  the  patient  is  seen  during  the  preliminary 
stage,  free  purgation  by  calomel  may  have  a  good  effect.  During 
the  attack  medicines  appear  to  be  of  little  use.  The  chief  indication 
seems  to  be  to  prevent  their  recurrence,  and  on  general  principles 
as  much  exercise  in  the  open  air  as  possible  should  be  secured. 
Too  long  hours  of  school  and  overstudy  generally  should  be  for- 
bidden. The  diet  should  be  carefully  regulated,  allowing  a  min- 
imum of  meats  and  a  considerable  quantity  of  fruits,  either  fresh  or 
stewed,  and  simple  farinaceous  foods.  During  the  intervals  be- 
tween the  attacks  the  antilithic  course  recommended  by  Rach- 
ford  may  be  employed. 

PYLORIC    HYPERTROPHY  WITH   STENOSIS. 

Congenital  hypertrophy  of  the  pyloric  end  of  the  stomach  with 
stenosis  of  the  pylorus  itself  is  a  rare  condition.  Several  cases 
have,  however,  been  recently  reported.  The  cause  of  the  stenosis 
is  usually  a  congenital  malformation  of  the  pylorus  or  the  pyloric 
end  of  the  stomach.  The  muscular  coats  of  the  parts  affected 
are  hypertrophied,  and  there  is  frequently  a  hyperplasia  of  the 
mucous  and  submucous  tissues. 

Symptoms. — The  symptoms  may  appear  immediately  after 
birth,  or  when  the  child  is  from  one  to  five  weeks  old.  The  child 
is  usually  restless,  desiring  drink,  but  attempts  at  swallowing  are 
soon  followed  by  vomiting.  Occasionally  at  first  the  vomiting 


ULCER    OF    THE    STOMACH    IN    CHILDREN.  185 

occurs  at  long  intervals,  but  rapidly  increases  in  frequency  until  it 
follows  all  attempts  at  swallowing.  The  vomited  matter  consists 
of  the  materials  swallowed,  together  with  a  moderate  amount  of 
mucus,  but  is  never  bile-stained.  The  tongue  is  clean.  The 
bowels  may  not  be  affected  so  far  as  regularity  of  movement  is 
concerned  ;  the  stools  are,  however,  small.  Nutrition  rapidly 
fails,  and  the  child  usually  dies  of  inanition.  It  is  well  to  re- 
member that  although  stenosis  of  the  pylorus  is  a  rare  condition, 
its  presence  should  be  suspected  in  cases  of  persistent  and  in- 
creasing attacks  of  vomiting  following  the  taking  of  fluids  in  young 
children,  especially  if  the  vomited  matter  contains  no  bile  and  the 
tongue  is  clean. 

Treatment. — The  first  indication  in  the  treatment  is  the  careful 
regulation  of  the  feeding.  The  amount  of  food  should  be  small, 
and  must  be  given  at  frequent  regular  intervals.  It  should  be  of 
such  a  character  as  to  be  easily  and  quickly  digested.  No  refuse 
food  should  be  allowed  to  accumulate,  for  it  must  be  remembered 
that  pyloric  stenosis  is  an  occasional  cause  of  gastric  dilatation, 
and  to  prevent  this  the  stomach  should  be  emptied  by  irrigation 
and  washed  out  once  or  twice  daily.  Vomiting,  when  it  occurs, 
is  generally  regarded  as  salutary,  and  unless  it  becomes  very 
severe,  no  effort  should  be  made  to  check  it.  If  no  food  can  be 
retained  and  nutrition  fails,  surgical  methods  must  be  considered. 
Meltzer,  of  New  York,  recommends  that  in  these  cases  a  typical 
pylorectomy  be  performed. 

ULCER  OF  THE  STOMACH  IN  CHILDREN. 

Gastric  ulcer  is  rare  before  puberty,  though  not  uncommon 
after  that  period.  Among  the  cases  reported  and  confirmed  by 
autopsy  a  certain  number  are  described  as  simple  perforating 
ulcers,  but  a  close  scrutiny  of  these,  as  pointed  out  by  Soltau 
Fenwick,  were  in  reality  secondary  to  definite  conditions  com- 
petent to  produce  them.  Several  varieties  are  described,  such 
as  hemorrhagic  erosion,  follicular  ulceration,  simple  ulceration, 
acute  and  chronic,  and  tubercular  and  malignant  ulceration. 

Occasionally  cases  of  aggravated  gastric  disturbance  are  met 
in  infants  and  young  children,  accompanied  by  symptoms  arous- 
ing grave  suspicion  of  ulceration,  which  get  well  and  the  diag- 
nosis can  not  be  confirmed.  Some,  again,  are  not  suspected  at 
the  time  to  be  cases  of  gastric  ulcer,  but  a  grave  anemia  or 
spanemia  sets  in  that  can  only  be  accounted  for  by  a  rapid  loss 
of  blood,  and  presumably  from  the  stomach,  in  the  absence  of 
evidence  pointing  to  loss  from  any  other  source. 


1 86  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

Causes. — The  age  at  which  ulceration  of  the  stomach  has 
been  found  ranges  gradually  all  the  way  from  a  few  hours  after 
birth  to  a  few  days,  and  thence  to  the  period  when  childhood 
merges  into  youth,  after  which  the  disease  is  much  more  fre- 
quent. Conditions  which  predispose  to  ulceration  of  the  stomach 
are  those  which  lower  the  integrity  of  the  blood  or  its  proper  dis- 
tribution and  depuration,  and  follow  upon  many  diseases,  such  as 
septicemia,  scurvy,  purpura,  hemophilia,  and  leukocythemia.  In 
these  cases  effusion  of  blood  into  the  gastric  mucous  membrane 
may  be  followed  by  tissue-necrosis.  Next  comes  the  persistence 
of  acute  catarrh  of  the  stomach,  rendering  the  tissues  more  vul- 
nerable to  local  or  systemic  disturbances.  Mere  mechanical  irri- 
tation of  these  tissues  alone  is  not  capable  of  producing  ulcera- 
tion ;  it  is  usually  necessary  to  assume  a  lowered  state  of  vitality, 
local  or  general  or  both,  in  order  that  other  causes  may  become 
operable. 

Acute  infectious  diseases,  such  as  typhoid  fever,  diphtheria, 
variola,  and  pneumonia,  are  frequently  followed  in  adults  by 
gastric  ulceration,  and  this  obtains  to  a  less  extent  in  children. 
This  is  true  also  of  burns  of  the  surface,  probably  due  to  result- 
ant hemorrhages  into  the  gastric  mucosa  wjiich  become  con- 
verted into  areas  of  necrosis. 

As  previously  stated,  abrasions  of  the  mucous  membrane  of 
the  stomach  tend  to  heal  readily  and  promptly  when  once  the 
cause  of  irritation  is  removed  and  rest  is  secured. 

Several  causes,  local  and  systemic,  conspire  to  delay  healing. 
Among  the  local  causes  which  prevent  repair,  the  anatomic  situ- 
ation of  the  lesion  is  a  highly  important  one.  Acute  ulceration 
of  the  stomach  is  almost  always  found  in  the  cardiac  or  middle 
zone,  near  the  greater  curvature  ;  a  few  instances  have  been 
found  in  which  it  occurred  near  the  lesser  curvature,  which  is  the 
common  situation  of  chronic  ulcer  in  adults. 

The  delay  in  the  healing  of  injuries  in  or  near  the  pyloric 
region  is  chiefly  due  to  want  of  rest,  as  this  is  the  area  of  greatest 
muscular  activity  of  the  viscus  and  is  practically  uncontrollable. 
Again,  the  structural  relationships  of  the  pyloric  region  are  such 
as  to  interfere  with  healing.  There  the  submucous  connective 
tissue  is  scanty  and  firmly  binds  the  surface  to  the  subjacent 
tissues. 

In  the  pyloric  region,  again,  the  blood  supply  is  deficient  and 
irregular,  presenting  unfavorable  conditions  for  prompt  repair. 
The  greatest  circulatory,  hence  functional,  activity  is  in  and  about 
the  fundus  and  central  portions  of  the  viscus. 

If  hyperchlorhydria  exists,  this  also   tends  to   delay  repair. 


ULCER    OF    THE    STOMACH    IN    CHILDREN.  l8/ 

Among  the  systemic  causes  of  delayed  healing  those  first  to  be 
considered  and  removed  are  morbid  states  of  the  blood.  Well- 
marked  anemias,  from  whatever  causes,  the  cachexiae  resulting 
from  syphilis,  malaria,  or  tuberculosis,  or  the  hemic  disorgani- 
zation following  upon  the  acute  infectious  fevers  obviously  inhibit 
cellular  repair.  Tubercular  ulceration  is  not  demonstrated  to  be 
a  common  condition,  although  various  grades  of  gastric  and  in- 
testinal ulceration  are  sometimes  seen  in  tuberculous  individuals. 
Encysted  collections  of  pus  arising  from  tubercular  peritonitis  and 
caseous  lymphatic  glands  which  discharged  into  the  stomach 
have  been  demonstrated.  Malignant  diseases  of  the  stomach  are 
extremely  rare  in  children. 

Symptoms. — In  young  children  the  most  prominent  and 
usually  the  earliest  indication  of  gastric  ulcer  is  the  vomiting  of 
blood  ;  in  them  subjective  symptoms  can  not  be  accurately  nor 
readily  interpreted.  It  should  be  borne  in  mind  that  this  may 
arise  from  other  causes,  as  from  lesions  in  the  nose  or  mouth.  It 
may  be  a  bright  arterial  blood  which  is  rejected  or  blackened 
by  the  action  of  the  gastric  secretions  on  the  hemoglobin. 

In  older  children  the  phenomena  are  usually  those  of  so-called 
"dyspepsia"  or  "indigestion,"  until  evidences  of  a  profound 
anemia  or  collapse  supervene  and  death  follows,  when  the  lesion 
is  exhibited  at  autopsy.  To  these  may  be  added  hematemesis, 
pain,  acute  or  dull,  or  varying  degrees  of  tenderness  on  pres- 
sure. Pain  after  a  meal  is  not,  as  a  rule,  so  pronounced  as  in 
adults,  but  occurs  and  may  be  severe.  Relief  is  found  in  vom- 
iting. The  location  of  pain  may  be  in  the  epigastrium  or  the 
back,  near  the  last  dorsal  or  first  lumbar  vertebra.  In  most 
cases  there  is  pain  or  tenderness  or  both  over  the  ensiform  car- 
tilage, pressure  on  which  induces  nausea  or  vomiting. 

Vomiting  is  a  variable  symptom,  and  is  generally  preceded  by 
nausea,  occurring  as  the  culmination  of  a  painful  crisis  and  fol- 
lowed by  relief  of  abdominal  pain.  Hematemesis,  always  sug- 
gestive of  gastric  ulcer,  is,  however,  not  pathognomonic  of  that 
disorder.  It  may  arise  from  fissured  nipples  of  the  mother, 
lesions  in  the  mouth,  pharynx,  or  nose  of  the  child  ;  it  often  fol- 
lows paroxysms  of  whooping-cough,  and  occasionally  complicates 
measles  and  variola.  In  diseases  of  the  blood,  as  scurvy,  pur- 
pura,  and  hemophilia,  it  is  often  a  prominent  feature. 

When  the  vomiting  of  blood  does  accompany  ulceration  of  the 
stomach,  the  amount  rejected  is  no  index  of  the  extent  of 
the  eroded  surface.  If  of  considerable  amount,  it  is  usually 
of  a  bright  arterial  color  and  indicates  that  a  large  vessel  is 
eroded.  Lesser  bleedings  are  followed  by  darker  material 


1 88  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

(melena),  evidently  slower  hemorrhage,  and  the  alterative  action 
upon  the  hemorrhage  by  the  gastric  juices. 

It  must  not  be  overlooked  that  bleeding  of  a  most  destructive 
nature  may  go  on  after  the  hematemesis  has  ceased,  owing  to  the 
lessened  reflex  activity  due  to  nervous  depression.  After  death 
from  this  cause  the  stomach  has  been  found  filled  with  blood. 
Hemorrhage  from  the  bowel  usually  accompanies  that  from  the 
stomach  and  may  replace  it,  by  producing  what  is  called  spurious 
hematemesis,  the  blood  being  forced  upward  from  the  intestine 
and  thence  rejected  by  the  stomach.  This  may  arise  from  many 
other  conditions  besides  gastric  ulcer,  and  is  especially  puzzling 
when  forced  up  into  the  stomach,  as  when  it  occurs  in  cases  of 
intussusception,  hemorrhoids,  and  rectal  congestions. 

The  evidences  of  intestinal  hemorrhage  are  profound  pallor 
and  collapse,  followed  by  evacuations  containing  blood.  In 
gastric  ulcer  the  bowels  are  usually  confined,  the  stools  very 
hard,  scybalous,  and  covered  with  thick  tenacious  mucus  ;  there 
is  rarely  flatulence,  but  often  acid  eructations.  Perforation  is  a 
much-to-be-dreaded  complication. 

Treatment. — Ulceration  of  the  stomach  is  often  first  mani- 
fested by  hematemesis,  and  if  so,  the  treatment  of  that  symptom 
is  urgently  demanded.  Again,  the  evidences  of  bleeding  may  be 
only  sudden  pallor  and  collapse,  and  remedies  must  be  directed 
toward  the  checking  of  hemorrhage  along  with  the  prompt  sup- 
ply of  intravascular  fluids,  among  which  intravenous  or  intracell- 
ular  saline  injections  stand  first  in  order. 

The  earliest  conclusive  symptoms  are  epigastric  pain  and  great 
tenderness.  These  must  be  relieved,  and  among  the  efficacious 
agents  opium  is  not  the  best,  because  it  is  excreted  by  the  glands 
of  the  stomach,  is  a  more  or  less  dangerous  drug  to  children,  and 
may  itself  cause  nausea  and  vomiting.  There  is  almost  invariably 
present  a  certain  amount  of  chronic  gastric  catarrh,  certainly 
in  those  beyond  the  earliest  infancy  ;  hence  a  careful  treatment 
of  this  state  will  tend  to  limit  the  ulcerative  process  and 
place  whatever  lesion  exists  in  the  gastric  mucosa  in  a  condition 
for  repair. 

In  chronic  gastric  catarrh  the  stomach  often  presents  loss  of 
motor  activity,  and  therefore  food  remains  unduly  long  in  that 
organ  ;  mucus  is  apt  to  be  overabundant,  viscid,  tough,  and 
adherent,  drowning  and  delaying  the  action  of  the  normal  secre- 
tions and  encouraging  fermentation.  The  reaction  of  the  con- 
tents is  acid,  chiefly  from  the  products  of  fermentation,  and  will 
show  lactic,  acetic,  butyric,  and  other  volatile  fatty  acids,  while 
the  normal  hydrochloric  acid  is  usually  markedly  deficient.  The 


ULCER    OF    THE    STOMACH    IN    CHILDREN.  189 

lab-ferfaent  and  pepsin  are  almost  invariably  present,  although 
deficient  in  quantity. 

Irrigation  will  remove  the  mucus,  the  offensive  and  irritating 
fatty  acids,  and  the  undigested  food,  and  will  encourage  the 
secretion  of  hydrochloric  acid,  thereby  quieting  the  reflex  dis- 
turbances and  pain  and  producing  comfort.  Vomiting  accom- 
plishes these  results  very  slowly  and  imperfectly. 

The  addition  of  an  alkali  to  the  sterile  water  in  lavage  is  often 
important  at  first,  and  at  a  later  irrigation  bismuth  may  be 
used  :  first  the  alkaline  solution  is  to  be  siphoned  out,  and 
immediately  the  bismuth  in  water  run  in  and  out.  In  this  way 
a  complete  cleansing  and  neutralizing  effect  is  secured,  and  thus 
an  excess  of  alkali  and  bismuth  can  be  used  which  is  at  once 
removed  and  does  not  remain  in  the  intestines,  as  would  be  the 
case  if  swallowed. 

If  the  irrigating  fluid  should  at  any  time  bring  away  blood, 
especially  after  the  earlier  washings,  or  when  other  evidence  exists 
of  open  lesions,  it  may  be  necessary  to  employ  an  astringent, 
such  as  alumnol,  silver  nitrate  or  albuminate,  or  some  prepara- 
tion of  the  vegetable  astringents,  such  as  gallic  acid.  These 
solutions  should  always  be  thoroughly  removed  immediately  by 
washing ;  in  the  case  of  silver  nitrate,  by  a  solution  of  sodium 
chlorid.  For  the  relief  of  pain  and  tenderness  the  lavage  of 
alternate  hot  and  cold  water  often  suffices  ;  or  orthoform  may 
be  added  to  the  solution.  Chloretone  is  worthy  of  trial,  either  by 
lavage  or  administration  by  the  mouth.  Cocain  and  morphin, 
though  of  great  efficacy,  must  be  employed  with  caution. 

One  of  the  most  efficacious  drugs  for  the  relief  of  gastric  pain 
is  the  rectal  injection  of  strontium  bromid,  as  first  recommended 
and  used  by  D.  D.  Stewart.  Small  blisters  over  the  epigastrium 
have  been  recommended  for  controlling  the  pain  and  nausea  of 
the  chronic  form,  but  they  have  proved  disappointing.  The  use 
of  a  moist  pad  over  the  abdomen,  such  as  the  Pressnitz  bandage, 
is  more  helpful. 

It  is,  of  course,  wise  to  give  the  stomach  no  labor  for  several 
days,  and  feeding  by  the  rectum  or  colon  will  readily  accomplish 
ample  support  for  a  very  long  period.  Leube's  pancreatic  emul- 
sion is  excellent  for  this  ;  somatose,  beef-extracts,  eggs,  and  pre- 
digested  milk  may  be  used  alternately  or  as  needed.  In  an  adult 
one  of  the  authors  has  seen  the  stomach  thus  relieved  for  over 
three  weeks  at  a  stretch,  and  in  children  from  a  week  to  ten 
days. 

Great  care  is  needed  in  returning  to  diet  by  the  mouth,  which 
at  first  should  be  in  the  form  of  peptonized  milk  or  peptonized 


I9O  DISEASES    OF   THE    DIGESTIVE    ORGANS. 

milk-gruel,  given  in  small  quantities  at  moderately  frequent 
intervals. 

The  introduction  of  the  stomach-tube  in  children  is  not  diffi- 
cult, and  rarely  causes  any  trouble.  It  is  best  done  when  the 
child  lies  on  its  side.  It  is  thus  largely  employed  in  the  acute 
milk  infections,  summer  complaints,  etc.,  in  our  dispensaries,  and 
has  seldom  caused  us  any  anxiety. 

Endless  remedies  have  been  advocated,  such  as  turpentine, 
chlorodyne,  etc.,  but  few  drugs  have  given  us  satisfaction  except 
those  mentioned.  A  word  should  be  said  about  bismuth  salts. 
These  are  of  value  in  proportion  as  they  are  mechanically  good, 
the  degree  of  comminution  being  of  more  importance  than  the 
chemic  preparation.  For  lavage  the  best  is  bismuth  subnitrate. 
If  fermentation  is  a  marked  feature,  the  subgallate  is  better  for 
internal  administration.  Hydrastinin  hydrochlorate  is  the  best 
vasoconstrictor  we  have  used,  and  will  check  bleeding  better 
than  ergot,  or  it  may  be  combined  with  the  latter  in  the  propor- 
tion of  -jljj-  to  \  grain  of  hydrastinin  hydrochlorate  to  ^  to  2  grains 
ergotin. 

GASTRALGIA. 

Definition. — The  term  gastralgia  is  applied  to  a  sudden, 
severe  attack  of  pain  in  the  gastric  region  unaccompanied  by 
inflammation. 

Causes. — The  condition  may  arise  from  exposure  to  cold,  by 
taking  cold  drinks,  especially  when  the  child  is  overheated,  or 
occasionally  by  getting  the  feet  wet.  Not  infrequently  it  appears 
as  a  form  of  neuralgia.  Holt  states  that  it  is  common  in  children 
affected  with  malaria,  especially  at  the  onset  of  the  attack.  The 
amount  of  pain  may  be  slight,  or  may  be  so  severe  as  to  cause 
faintness  or  marked  prostration.  No  inflammatory  symptoms 
accompany  the  pain. 

Treatment. — The  patient  should  be  put  at  rest  in  bed,  and 
counterirritation  over  the  stomach  applied  by  means  of  a  tur 
pentine  stupe,  mustard  plaster,-  or  hot-water  bag.  Internally 
should  be  given  moderate  quantities  of  hot  water  containing  five 
drops  of  spirits  of  chloroform,  Hoffmann's  anodyne,  brandy, 
whisky,  or  gin.  If  the  pain  is  severe  enough  to  cause  prostra- 
tion, heat  should  be  applied  to  the  body  and  all  food  withheld 
during  the  attack.  Recurrent  cases  are  best  treated  by  the  use 
of  arsenic  in  the  form  of  Fowler's  solution.  Attention  should 
also  be  directed  to  the  patient's  general  health  and  to  careful 
regulation  of  the  digestion. 


DILATATION    OF    THE    STOMACH.  19! 


DILATATION    OF    THE   STOMACH. 

Frequently  the  stomach  becomes  dilated  as  the  result  of  long- 
continued  chronic  catarrh  of  its  mucous  membrane.  The  con- 
dition is  most  commonly  found  in  artificially  fed  rachitic  or  anemic 
children.  Occasionally  it  arises  from  acute  gastro-enteritis  and 
cholera  infantum.  It  is  also  seen  as  a  secondary  consequence 
of  congenital  stenosis  of  the  pylorus  or  obstruction  of  the  duo- 
denum and  ileum.  (See  article  on  this  subject.) 

Pathology. — As  a  result  of  weakness  and  insufficiency  of  the 
digestive  fluids  decomposition  of  the  casein  of  milk  and  all  starchy 
elements  takes  place,  resulting  in  the  formation  of  large  quanti- 
ties of  gas.  These  keep  the  weakened  muscular  coats  continu- 
ally on  the  stretch,  and,  as  a  result,  atrophy  of  the  muscular  fibers 
and  glands  takes  place  ;  such  a  stomach  is  never  entirely  emptied, 
but  always  contains  more  or  less  decomposing  food  and  mucus, 
from  which  often  results  an  autointoxication.  .  The  size  of  the 
stomach  in  this  condition  is  sometimes  very  great.  Thus,  Hen- 
schel  records  the  case  of  the  stomach  of  an  infant  two  weeks  old 
the  capacity  of  which  was  190  c.c.,  the  normal  capacity  being  70 
c.c.,  and  he  also  gives  an  account  of  the  stomach  of  an  infant  of 
three  months  whose  gastric  capacity  was  485  c.c.,  the  normal 
capacity  being  I  50  c.c.  Other  cases  showing  the  great  increase 
in  size  of  the  stomach  owing  to  dilatation  are  reported  by  the 
same  author  and  others. 

Symptoms. — The  symptoms  of  gastric  dilatation  are  fre- 
quently vague,  and  it  is  not  uncommon  for  the  condition  to  be 
discovered  only  at  the  autopsy.  Such  symptoms  as  chronic 
dyspepsia,  regularly  occurring  discomfort  after  taking  food,  and 
habitual  vomiting  after  meals  may  lead  us  to  suspect  the  con- 
dition. The  child  complains  of  pain  after  eating  for  some  days, 
and  then  suddenly  vomits  large  quantities  of  partially  digested 
fermented  curds  or  the  remains  of  other  food  taken  during  this 
time.  The  tongue  is  heavily  coated,  there  is  frequently  consti- 
pation, and  the  child  shows  symptoms  of  general  nutritional 
failure. 

Diagnosis. — Owing  to  the  obscurity  of  the  symptoms  the 
diagnosis  may  not  be  easy.  Sometimes  the  dilated  stomach  may 
be  mapped  out  by  percussion,  but  should  the  large  intestine  also 
be  distended,  this  method  of  diagnosis  in  a  child  is  by  no  means 
an  easy  matter ;  in  fact  in  the  majority  of  cases  it  is  impossible, 
as  the  tympanitic  percussion-note  would  be  the  same  over  both. 
It  is  said  that  a  splashing  sound  may  occasionally  be  produced 


DISEASES    OF    THE    DIGESTIVE    ORGANS. 

by  shaking  the   child   gently,  but  this  sound  can  only  be  heard 
when  the  stomach  is  full  of  fluid. 

Treatment. — The  treatment  is  that  of  chronic  gastric  indiges- 
tion. The  food  should  be  carefully  modified  and  given  in  small 
quantities  at  regular  intervals.  Irrigation  of  the  stomach  is 
especially  indicated.  Strychnin  or  nux  vomica,  arsenic,  and  the 
mineral  acids,  particularly  hydrochloric,  are  the  chief  remedies  to 
be  employed.  Such  children  should  be  kept  in  the  best  of  hygi- 
enic surroundings  and  allowed  a  life  in  the  open  air  as  much  as 
possible. 


DISEASES   OF   THE    INTESTINES. 

MALFORMATIONS  OF  THE  INTESTINAL  TRACT. 
STENOSIS  AND  ATRESIA. 

Narrowing  or  closure  may  occur  at  any  part  of  the  intestinal 
tract.  The  causes  may  be  divided  into  congenital  and  acquired. 
The  congenital  form  is  usually  due  to  the  formation  of  cicatrices 
resulting  from  intestinal  ulcer  occurring  during  intra-uterine  life. 
The  condition  may  also  arise  from  the  formation  of  peritoneal 
bands  or  tumors  arising  during  intra-uterine  life.  The  acquired 
form  may  be  caused  by  chronic  intestinal  ulcerations  or  mechan- 
ical irritation  of  the  intestines  arising  during  the  course  of  dysen- 
tery or  certain  forms  of  chronic  diarrhea.  Occasionally  the  rectum 
ends  in  a  blind  pouch  without  the  formation  of  the  anal  opening. 
In  this  condition  the  rectum  may  terminate  at  any  point  below 
the  sigmoid  flexure.  In  some  cases  it  is  attached  directly  to  the 
floor  of  the  perineum,  producing  a  tumor  of  the  latter  as  the 
meconium  collects  and  distends  the  blind  end  of  the  bowel. 

Treatment. — Immediately  following  birth  the  physician 
should  examine  the  infant  to  see  if  the  parts  around  the  anus 
are  properly  formed.  Ordinarily,  soon  after  it  is  born  the  child 
has  a  free  passage  of  meconium  ;  if  this  does  not  occur,  exami- 
nation of  the  rectum  ought  to  be  made  with  the  finger,  and  should 
any  malformation  be  found,  it  will  probably  be  necessary  to  use 
surgical  means  for  the  relief  of  the  condition.  In  cases  where 
the  rectum  ends  in  a  blind  extremity  which  is  near  to  the  surface 
of  the  perineum,  the  intervening  partition  can  be  broken  through 
by  means  of  a  grooved  director,  and  an  opening  made  with  the 
finger.  If  a  considerable  amount  of  tissue  lies  between  the  sur- 
face and  the  rectum,  it  will  be  necessary  to  dissect  systematically 


,  ACUTE    ENTERITIS.  193 

upward  in  search  of  the  rectal  opening.  In  doing  this  a  staff 
should  be  placed  in  the  bladder  as  a  guide.  Should  this  fail, 
Rotch  advises  that  Littre's  operation  be  performed.  This  con- 
sists in  opening  the  sigmoid  flexure  in  the  inguinal  region  and 
making  an  artificial  anus  ;  or  an  attempt  may  be  made  to  cut 
through  the  sacrum  and  make  an  opening  into  the  gut  at  this 
point. 

ACUTE    ENTERITIS. 

Synonyms. — ACUTE  INTESTINAL  INDIGESTION  ;  ACUTE  CATARRHAL 
ENTERITIS  ;  SIMPLE  DIARRHEA  ;  MECHANICAL  DIARRHEA. 

Causes. — Food  given  in  too  large  quantities  or  of  a  sort  not 
adapted  to  the  age  and  condition  of  the  child,  irregular  feeding, 
the  use  of  a  dirty  nursing-bottle,  the  too  early  and  frequent  use 
of  table  foods,  and  bad  hygiene  may  be  accepted  as  the  most 
usual  causes  of  acute  enteritis.  Any  or  all  of  these  causes  may 
increase  the  severity  of  the  attacks  when  they  occur  during  the 
period  of  dentition,  at  which  time  the  entire  nervous  system 
of  the  child  is  readily  influenced  by  external  causes,  and  the 
digestive  tract  is  in  a  condition  which  may  be  termed  hyper- 
esthetic.  Another  predisposing  cause  may  be  sudden  changes 
of  the  temperature,  especially  a  rapid  change  from  cool  weather 
to  hot. 

Symptoms. — The  attack  of  enteritis  usually  begins  with  an 
increased  number  of  stools,  averaging  anywhere  from  five  to 
twenty  a  day.  The  bowel  movements,  which  for  the  first  two  or 
three  evacuations  are  normal  in  color  and  consistency,  rapidly 
change  to  liquid  or  soft  unformed  masses  of  a  greenish  or 
yellowish  hue.  All  the  bowel  movements  contain  curds  and 
more  or  less  mucus  ;  later  they  may  be  streaked  with  blood. 
The  evacuations  are  preceded  by  pain  and  tenesmus.  In  a  few 
hours  the  child  suffers  some  loss  of  flesh,  which  is  particularly 
manifest  in  the  face  and  limbs.  When  the  attack  is  of  short 
duration,  the  abdomen  may  be  painless  on  pressure,  but  as  a 
general  rule  the  child  will  complain  of  some  pain  in  this  region 
on  palpation  in  a  few  hours  if  the  attack  continues.  Vomiting 
may  or  may  not  be  present.  Occasionally  the  disease  is  ushered 
in  by  convulsions,  but  this  symptom  shows  a  severe  degree  of 
intestinal  irritation  or  poisoning.  Thirst  is  nearly  always  a 
prominent  feature.  More  or  less  distention  of  the  abdomen  is 
usually  found  during  the  first  hours  of  the  disease.  The  pulse, 
although  increased  in  frequency  during  the  attacks  of  pain,  is 
not  usually  much  above  normal.  If  fever  is  present,  it  is  rarely 
13 


194  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

constant,  but  some  irregular  increase  of  temperature  is  generally 
observed. 

Prognosis. — The  prognosis  is  favorable  under  proper  treat- 
ment. The  principal  danger  consists  in  allowing  the  irritating 
masses  of  food  to  remain  in  the  intestines  long  enough  to  set  up 
a  condition  of  chronic  inflammation. 

Treatment. — When  the  case  is  seen  early,  a  dose  or  two  of 
a  dram  of  castor  oil  will,  in  many  cases,  remove  the  irritating 
masses  of  undigested  foods.  When  the  child  is  old  enough,  this 
may  be  given  in  the  form  of  a  soft  capsule,  each  one  containing 
from  five  to  ten  drops  of  oil.  In  young  children  the  remedy  may 
be  given  in  emulsion  or  sandwiched  between  two  layers  of  five  or 
ten  drops  of  whisky  or  brandy,  or  the  oil  may  be  introduced  into 
the  rectum.  Calomel  is  indicated  in  these  cases  ;  it  may  be 
either  given  alone  or  preferably  in  combination  with  salol  or 
bismuth.  An  effective  mixture  used  by  us  in  hundreds  of  dis- 
pensary cases  consists  of  equal  parts  of  lime-water  and  cinnamon 
water,  of  which  two  drams  are  given  every  hour  or  two,  and  often 
three  grains  of  bismuth  subgallate  are  added.  Where  calomel  is 
used  in  these  cases,  the  drug  acts  not  only  by  its  laxative  effect, 
but  also  by  increasing  the  flow  of  bile  into  the  intestines.  When 
the  amount  of  pain  is  very  great,  the  aromatic  syrup  of  rhubarb, 
in  doses  of  from  a  dram  to  half  an  ounce,  will  be  found  useful. 
Occasionally  a  few  drops  of  camphorated  tincture  of  opium  may 
be  combined  with  any  of  the  before-mentioned  agents  to  relieve 
pain.  It  should  be  distinctly  understood,  however,  that  the  use 
of  opiates  in  cases  of  acute  indigestion  is  not  to  be  encouraged,  nor 
are  astringents  to  be  given  until  the  intestine  has  been  thoroughly 
cleansed  of  the  irritating  cause  of  the  attack.  In  most  cases  the 
thorough  evacuation  of  the  intestines  should  be  encouraged  by 
copious  enemata  of  boiled  water  containing  a  small  amount  of 
Castile  soap,  ten  or  fifteen  grains  of  bismuth  subnitrate,  or  i  per 
cent,  of  sodium  chlorid. 

The  diet  is  a  matter  of  great  consideration.  When  the  child 
has  been  fed  by  the  bottle,  all  milk,  or  preparations  containing  it, 
should  be  stopped  until  the  bowel  movements  regain  their  normal 
character.  During  the  first  six  or  eight  hours  of  the  time  during 
which  milk  diet  is  withheld  the  patient  should  receive  small 
quantities  of  sterilized  water  containing  fifteen  or  twenty  drops 
of  brandy  every  two  or  three  hours.  At  the  end  of  this  time  it 
is  our  custom  to  give  the  child  a  teaspoonful  of  egg-water,  made 
by  gently  stirring  the  whites  of  two  eggs  in  a  half  pint  of  water 
and  adding  a  pinch  of  salt,  every  two  hours,  or  this  may  be  varied 
by  a  teaspoonful  of  freshly  pressed  beef-juice  or  liquid  peptonoids. 


CHRONIC    ENTERITIS.  1 95 

If  the  child  needs  nourishment,  it  may  be  fed  every  hour  with  the 
above — one  hour  with  liquid  peptonoids,  the  next  with  egg- 
water. 

In  twenty-four  hours  after  the  stools  have  resumed  their 
normal  color  the  child  may  be  gradually  returned  to  its  usual 
diet ;  it  is  well,  however,  to  give  the  patient  a  drop  or  two  of 
tincture  of  nux  vomica  three  or  four  times  a  day  before  feeding, 
in  order  to  stimulate  the  assimilative  action  of  the  intestines. 
Small  doses  of  calomel  or  bismuth,  or  a  combination  of  both, 
should  be  given  for  some  days  after  the  attack  has  ceased.  A 
useful  formula  is  the  following  : 

R  .     Hydrarg.  chlorid.  mite, gr.  ^ 

Bismuth,  submit., gr.  v. 

Sic. — One  powder  to  be  given  every  four  hours  for  five  days  after  the  diar- 
rhea has  ceased. 

We  have  also  found  the  following  to  be  useful,  especially  when 
vomiting  is  present : 

R .      Liq.  calcis, 

Aq.  cinnamomi, 

Aq.  chloroformi, aa^j. 

Sic. — One  dram  every  ten  or  fifteen  minutes  to  allay  gastric  and  intestinal 
irritation  and  as  an  antiseptic. 


CHRONIC  ENTERITIS. 

Synonyms. — CHRONIC  INTESTINAL  INDIGESTION  ;  CHRONIC  CATAR- 

RHAL  ENTERITIS  ;  CHRONIC  IRRITATIVE  DIARRHEA  ;  CHRONIC 

INTESTINAL  CATARRH  ;  CHRONIC  ENTEROCOLITIS. 

Causes. — The  causes  of  chronic  intestinal  catarrh  are  contin- 
uation or  return  of  a  series  of  attacks  of  acute  intestinal  indiges- 
tion ;  the  continued  use  of  improper  foods,  especially  at  the  period 
of  dentition.  Chronic  enteritis  may  follow  any  of  the  infectious 
diseases,  exposure  to  cold  and  wet,  or  bad  hygienic  surroundings. 
Chronic  intestinal  catarrh  is  fully  as  common  in  winter  as  in 
summer,  although  the  type  seen  in  the  hot  months  is  severer  and 
runs  its  course  quicker  than  in  cold  weather.  The  disease  is 
most  commonly  seen  from  the  third  month  to  the  end  of  the 
second  year,  and  is  much  more  frequent  in  artificially  fed  chil- 
dren than  in  those  fed  from  the  breast ;  indeed,  providing 
that  syphilis,  rickets,  or  struma  is  not  present,  it  is  somewhat 
rare  to  find  chronic  intestinal  catarrh  in  breast-fed  babies.  The 
majority  of  cases  are  caused  by  attempts  at  feeding  a  nursing 
child  on  a  badly  prepared  artificial  food,  especially  condensed 
milk  or  tainted  cow's  milk. 


196  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

Symptoms. — The  diarrhea  that  has  been  present  during  an 
acute  attack  continues,  or  returns  after  a  period  of  cessation. 
The  bowel  movements  are  watery,  or  they  may  occasionally 
change  to  semiformed  masses  of  a  grayish- white,  putty-like  hue 
and  consistence.  They  contain  undigested  food  and  much  mucus. 
Occasionally  they  are  streaked  with  blood  and  pus.  Green 
stools  are  common,  and  these  may  last  for  quite  a  considerable 
period,  particularly  at  the  beginning  of  each  exacerbation  of  the 
disease.  The  stools  are  found,  on  microscopic  examination,  to 
contain  swarms  of  bacteria  ;  their  odor  is  offensive  and  putrid, 
but  rarely  do  they  have  the  peculiar  musty  smell  of  the  large, 
watery  passages  of  true  cholera  infantum.  The  number  of  the 
stools  will  usually  average  from  four  to  ten  a  day,  and  are  preceded 
and  accompanied  by  considerable  pain  and  tenesmus.  The  dis- 
ease is  subject  to  distinct  exacerbations,  and  it  is  not  infrequent 
for  the  medical  attendant  to  imagine  that  he  has  the  case 
well  under  control  and  later  to  find,  to  his  discouragement,  that 
the  disease  has  returned  with  renewed  vigor.  These  cases  im- 
peratively require  careful  attention  and  patience,  not  only  on  the 
part  of  the  physician,  but  also  on  the  part  of  those  having  charge 
of  the  little  patient.  While  a  moderate  loss  of  weight  is  sure  to 
appear  finally,  and,  indeed,  may  become  very  great,  it  is  not  in- 
frequent to  see  patients  stand  the  continued  drain  on  the  system 
from  diarrhea  and  lack  of  assimilation  of  food  remarkably  well. 
The  loss  of  flesh  is  particularly  noticed  in  the  limbs  and  face,  the 
former  losing  their  roundness  of  shape  and  firmness  to  the  touch 
and  the  latter  its  characteristic  plumpness  and  happy  expression. 
The  facial  expression  of  these  children  is  remarkably  old,  thin, 
and  tired.  The  fontanel  is  depressed,  and  the  lower  part  of  the 
face  assumes  an  angular  shape  which  is  eminently  characteristic. 
The  abdomen  is  either  depressed  or  considerably  swollen  ;  the 
child  is  fretful,  cries  a  great  deal,  and  is  extremely  restless  during 
sleep,  young  children  tossing  and  frequently  crying  out,  and 
older  children  exhibiting  the  group  of  symptoms  known  as  night- 
terrors.  The  appetite  is  capricious,  sometimes  almost  lost  and  at 
other  times  the  child  manifests  a  ravenous  desire  for  food.  Oc- 
casional attacks  of  constipation  are  not  infrequent.  The  tongue 
is  red,  dry,  or  may  be  covered  by  a  brownish  or  yellowish  coat. 
Relaxation  and  prolapse  of  the  rectum  are  not  uncommon.  The 
skin  is  often  dry  and  scurfy.  The  temperature  is  generally  normal, 
although  short  periods  of  slight  pyrexia  are  not  infrequently 
seen.  Many  of  these  cases  run  their  course  without  gastric  com- 
plications. 

Diagnosis. — Although    the    diagnosis    of   chronic    intestinal 


CHRONIC    ENTERITIS.  1 97 

catarrh  is  by  no  means  difficult,  cases  presenting  the  before- 
mentioned  symptoms  should  be  carefully  examined  before  a 
positive  opinion  is  given.  The  disease  may  occasionally  be  con- 
founded with  general  tuberculosis  with  intestinal  complications  ; 
but  in  tubercular  affections  we  have  the  regular  daily  rise  and 
fall  of  temperature,  the  large  watery  bowel  movements,  and 
probably  evidences  of  tubercle  in  other  parts  of  the  body,  espe- 
cially the  glands  and  lungs. 

Prognosis. — The  prognosis  depends  in  great  measure  upon  the 
duration  of  the  disease,  the  general  constitutional  condition  of 
the  child,  and  the  treatment  it  receives.  The  coexistence  of  other 
diseases,  such  as  syphilis,  tuberculosis,  rachitis,  etc.,  makes  the 
prognosis  more  unfavorable.  Amid  good  hygienic  surroundings, 
with  careful  regulation  of  the  diet  and  the  administration  of  proper 
remedies,  the  prognosis  is  generally  favorable,  although  the 
duration  of  the  condition  is  usually  rather  tedious. 

Treatment. — The  success  of  the  treatment  of  chronic  gastro- 
intestinal catarrh  depends  far  more  upon  the  food  and  general 
surroundings  of  the  child,  its  place  of  living,  its  bathing,  clothes, 
etc.,  than  upon  the  administration  of  any  drugs.  In  young  chil- 
dren nursing  from  the  breast  the  composition  of  the  milk  should 
be  carefully  investigated.  The  existence  of  pregnancy,  prolonged 
hard  work,  nervous  excitability,  prolonged  lactation,  and  many 
other  causes  may  so  alter  the  constitution  of  the  mother's  or 
nurse's  milk  as  to  produce  chronic  dyspepsia  in  the  child.  In 
such  cases,  of  course,  the  diet  should  be  regulated,  and,  if  pos- 
sible, another  wet-nurse  should  be  substituted,  or,  when  the  child 
is  nursing  from  the  mother's  breast,  it  should  be  provided  either 
with  a  wet-nurse  or  placed  on  artificial  diet.  It  is  extremely 
difficult  to  lay  down  any  fixed  rule  for  the  diet  of  these  children. 
The  child  should  be  nourished  on  that  class  of  foods  which  is 
most  easily  digested  and  assimilated  by  the  strongest  part  of  its 
digestive  tract.  In  many  cases  the  stools  will  contain  large 
undigested  masses  of  casein  or  fat,  or  they  may  be  highly  acid  ; 
especially  is  this  the  case  when  the  child  has  been  fed  on  foods 
rich  in  lactose.  In  this  class  of  cases  all  milk  should  be  prohib- 
ited and  the  child  fed  for  a  considerable  period  on  beef  pepto- 
noids,  panopeptone,  meat-extracts,  albumin-water,  broths,  or 
other  species  of  proteid  foods.  When  the  stools  are  alkaline  in 
reaction,  frothy,  or  putrid,  a  moderate  diet  of  starchy  or  dextrinized 
foods  or  foods  containing  some  sugar  will  often  answer  admirably. 
It  must  be  borne  in  mind,  however,  that,  as  a  general  rule,  no 
child  under  eight  months  of  age  will  thrive  continuously  on  a 
diet  of  starch.  Modified  milk  containing  a  low  proportion  of 


198  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

sugar  and  fat  and  a  high  percentage  of  proteids  is  often  of  great 
use,  and  to  this  should  be  added  10  or  15  per  cent.,  by  bulk, 
of  lime-water.  Peptonized  milk,  either  alone  or  combined  with 
arrow-root,  is  sometimes  of  service,  but  this  diet  can  not  be  kept 
up  for  long.  Irr  older  children  the  diet  is  a  matter  of  the  greatest 
importance,  but  it  is  often  very  difficult  for  the  physician  to  con- 
trol and  direct  it  in  a  satisfactory  manner.  All  irregular  meals, 
highly  seasoned  foods,  candies,  and  most  of  the  sweet  cakes  must 
be  strictly  prohibited.  It  is  far  better  that  the  child  should  occa- 
sionally receive  too  little  food  than  that  it  should  eat  food  of  im- 
proper quality  or  in  quantities  too  large  for  its  temporary  capacity. 
The  following  diet-list  has  been  recommended  by  Starr  for  these 
cases,  this,  however,  being  subject  to  modifications  and  frequent 
changes. 

Breakfast. — At  8  A.M.,  a  teacupful  of  bread  and  milk  ;  the 
milk  should  be  rendered  alkaline  by  the  addition  of  lime-water. 
In  not  very  severe  cases  a  lightly  boiled  or  poached  egg,  with  one 
or  two  slices  of  bread  made  from  unbolted  flour,  or  stale  bread, 
with  butter,  may  be  substituted  for  the  bread  and  milk. 

Dinner. — At  noon  a  lean  broiled  mutton  chop  or  a  piece  of 
underdone  tender  roast  beef ;  such  vegetables  as  cauliflower  or  a 
small  quantity  of  well-roasted  potato  (not  new)  may  be  added. 
A  small  quantity  of  bread  well  toasted  or  Zwieback  ;  occasion- 
ally a  half  an  ounce  of  good  sherry  well  diluted. 

A  4  P.M.  about  twelve  ounces  of  fresh  milk,  rendered  alkaline 
as  previously  mentioned. 

At  7  P.M.  supper :  a  cup  of  beef- tea  or  mutton  broth. 

A  diet-list  such  as  the  preceding  may  be  continued  as  long  as 
the  child  does  well.  Whenever  a  relapse  occurs,  a  return  to  a 
strict  diet  of  modified  milk,  or,  better,  beef-juice,  beef-tea,  or 
chicken  or  mutton  broth,  given  in  small  quantities  at  regular  in- 
tervals, and  this  plain  diet  continued  until  the  bowel  movements 
have  become  normal  in  color  and  have  been  free  from  mucus  for 
a  number  of  days.  The  question  of  the  climate  and  general 
surroundings  of  the  child  is  one  for  earnest  consideration.  Chil- 
dren with  intestinal  disease,  particularly  of  a  chronic  form,  do 
much  better  in  the  country  than  in  the  city,  but  they  improve 
more  rapidly  at  the  seashore  than  anywhere  else.  It  is  also  of 
importance  that  such  children  be  kept  in  the  air,  and  they  should 
be  encouraged  to  play  out-of-doors.  Even  in  winter,  providing 
the  weather  is  not  too  windy  or  damp,  they  should  be  kept  in  the 
open  air  for  a  considerable  portion  of  each  day.  The  clothing 
should  be  of  wool,  and  so  constructed  as  to  impede  as  little  as 
possible  the  free  movement  of  the  limbs. 


CHRONIC    ENTERITIS.  199 

Medicinal  Treatment. — The  medicinal  treatment  should  be 
directed  first  toward  thoroughly  clearing  the  intestinal  tract  of 
the  irritating  cause  of  the  disease,  and,  secondly,  stimulating  the 
digestive  and  assimilative  powers.  For  the  first,  laxative  closes 
of  castor  oil  are  occasionally  of  great  use.  Calomel,  also,  is  an 
exceedingly  useful  drug  for  this  purpose.  It  is  best  given  in 
small  and  frequently  repeated  doses,  and  may  be  combined  ad- 
vantageously with  salol  or  bicarbonate  or  phosphate  of  sodium. 
Beta-naphthol  bismuth,  in  doses  of  from  one  to  five  grains  re- 
peated every  few  hours,  has  been  highly  recommended  by  Dr. 
Lewis  Fischer  and  others.  The  following  prescription  is  recom- 
mended by  Rotch  : 

Podophyllin, I  grain 

Alcohol, I  dram. 

Give  from  three  to  five  drops,  according  to  the  age  of  the  child, 
repeated  morning  and  evening,  the  dose  to  be  lessened  if  it  causes 
more  than  two  discharges  a  day.  Tonics,  and  particularly  arsenic 
and  nux  vomica,  should  be  given.  From  one  to  five  drops  of  the 
tincture  of  nux  vomica  given  immediately  after  taking  food  forms 
an  excellent  digestive  tonic.  Of  the  intestinal  astringents,  bismuth 
is  probably  the  best :  doses  of  from  five  to  ten  grains  of  the  sub- 
gallate,  salicylate,  or  subnitrate,  given  either  alone  or  in  combi- 
nation with  salol,  give  excellent  results.  In  many  cases  bismuth 
may  be  advantageously  administered  by  means  of  enemata  applied 
to  the  lower  bowel.  Opiates,  as  a  rule,  are  distinctly  contrain- 
dicated.  Probably  one  of  the  most  successful  methods  of  treat- 
ment is  by  copious  enemata  of  warm  sterilized  water  or  normal 
salt  solution  ;  the  latter  has  been  recommended  by  Fischer,  of 
New  York.  From  three  to  four  quarts  of  water  should  be 
used  at  each  irrigation.  They  should  be  given  from  a  fountain 
syringe,  to  which  is  attached  a  large-sized  soft  catheter  having 
more  than  one  opening.  The  child  should  lie  on  the  nurse's 
lap,  either  on  its  back  or  in  what  we  have  found  to  be  better 
positions — namely,  on  the  abdomen  or  left  side.  The  syringe 
should  be  held  about  three  feet  above  the  floor,  and  the  water 
should  be  allowed  to  flow  in  and  out  again.  It  is  often  neces- 
sary to  flush  out  the  intestines  thoroughly  with  either  plain 
boiled  water  or  normal  salt  solution,  in  order  to  clear  them 
before  administering  the  enema  containing  the  intestinal  antiseptic 
or  astringent.  Probably  the  best  antiseptic  to  be  given  in  this 
way  is  a  combination  of  subnitrate  of  bismuth  and  salol,  or  beta- 
naphthol  bismuth.  They  should  be  administered  in  a  half  pint 


2OO  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

or  so  of  water,  allowed  to  flow  into  the  intestine,  and  remain 
there. 

When  anemia  is  a  complication  of  this  disease,  and  especially 
if  it  persists  after  the  recovery  of  the  child,  some  of  the  numer- 
ous preparations  of  iron  are  indicated.  While,  as  a  rule,  cod- 
liver  oil  or  any  of  the  vegetable  oils  are  contraindicated  when 
administered  by  the  mouth,  yet  not  infrequently  we  find  excellent 
results  following  inunctions  of  these  applied  to  the  abdomen  or 
over  the  body  generally.  The  benefit  of  these  inunctions  is 
undoubtedly  increased  when  accompanied  by  massage. 

ACUTE    MILK   INFECTION. 

Synonyms. — CHOLERA   INFANTUM  ;    THE  TERM  "  CHOLERIFORM  " 
is  SOMETIMES  USED. 

The  disease  here  described  as  acute  milk  infection  is  that  form 
of  acute  intestinal  poisoning  produced  by  those  bacterial  toxins 
peculiar  to  milk  and  foods  containing  milk. 

Acute  milk  infection  is  a  disease  peculiar  to  the  summer 
months,  and  is  found  only  in  children  fed  on  an  artificial  diet  of 
foods  containing  milk.  It  occurs  very  rarely  in  children  fed 
upon  breast  milk,  although  occasionally  such  cases  have  been 
reported. 

Causes. — The  specific  poison,  bacterial  or  chemic,  producing 
cholera  infantum  has  not  yet  been  isolated.  In  the  healthy 
nursing  child  two  forms  of  bacteria  are  constantly  found  in  the 
intestinal  tract ;  these  are  the  bacterium  lactis  aerogenes  and  the 
bacterium  coli  communis.  These  are  sometimes  called  the 
"  obligatory  milk  feces  "  bacteria.  According  to  the  researches 
of  Baginsky,  Booker,  and  others,  the  upper  part  of  the  duodenum 
is  quite  free  from  micro-organisms,  while  the  lower  part  of  the 
small  intestines  contains  considerable  numbers  of  the  bacterium 
lactis  aerogenes.  The  bacillus  coli  communis  has  been  found 
chiefly  in  the  lower  part  of  the  ileum,  and  still  more  abundantly 
throughout  the  entire  length  of  the  colon.  Whether  or  not  the 
poison  is  due  to  a  sudden  increase  in  number  of  these  bacteria  or 
their  ptomains,  produced  partly  by  the  continued  high  tempera- 
ture of  the  summer  and  aided  by  a  fermentation  of  artificial  foods 
in  the  intestines,  or  whether  it  is  due  to  some  specific  microbe 
which  has  its  existence  only  during  the  warmer  months,  is  still 
an  unsettled  question.  Certain  it  is,  however,  that  true  cholera 
infantum — acute  milk  infection — is  almost  solely  found  during 
the  summer  months.  It  is  a  disease  much  commoner  in  cities 
than  in  the  country,  and  the  number  of  cases  increase  during  the 


ACUTE    MILK    INFECTION.  2OI 

prevalence  of  a  temperature  above  70°  F.  (21.1°  C.).  The  chil- 
dren of  the  poor  are  oftener  attacked  than  those  in  better  circum- 
stances, and,  as  before  stated,  it  is  found  almost  entirely  in  chil- 
dren fed  on  artificial  foods  containing  milk  or  on  unsterilized 
cow's  milk,  and  some  of  the  very  worst  cases  that  we  have  seen 
have  been  among  infants  fed  on  condensed  milk.  It  appears 
most  frequently  from  the  third  month  to  the  end  of  the  second 
year.  Although  the  toxic  bacteria  are  most  frequently  intro- 
duced into  the  system  in  the  manner  before  stated,  they  may 
enter  in  other  ways,  as  by  the  anus  or  by  the  mouth  from  the 
nipple  of  a  mother  or  nurse  whose  habits  are  uncleanly.  An 
infant  may  infect  itself  from  its  own  fingers,  which  in  many  cases 
are  far  from  clean. 

Pathology. — In  infants  dying  after  an  acute  attack  of  milk 
infection  of  short  duration,  we  find. a  very  considerable  amount 
of  emaciation,  much  more  marked  in  the  face,  however,  than  in 
the  body  ;  the  cheeks  and  eyes  are  sunken,  and  the  fontanel  is 
depressed.  If  the  disease  has  lasted  for  some  days,  the  loss  of 
bodily  weight  is  extreme  ;  the  limbs  lose  their  rounded  shape, 
and  the  skin  covering  the  upper  part  of  the  thighs  is  loose  and 
hangs  in  folds.  The  face  has  entirely  lost  its  plumpness  and 
shows  extreme  emaciation.  Upon  opening  the  body,  examina- 
tion will  show  minute  hemorrhages  upon  the  surfaces  of  the 
lungs,  with  evidences  of  hypostatic  congestion  at  their  bases. 
The  same  minute  hemorrhages  are  found  in  the  heart,  which  is 
usually  in  a  state  of  diastole,  its  cavity  being  filled  with  blood. 
The  mucous  membranes  of  the  stomach  and  intestines  are  in  a 
condition  of  capillary  congestion,  with  small  hemorrhagic  patches 
scattered  here  and  there.  The  contents  of  the  intestines  are 
liquid,  from  an  excessive  secretion  of  mucus.  Peyer's  patches 
and  the  solitary  glands  are  swollen.  There  is  marked  conges- 
tion of  the  mucous  membrane  of  the  entire  large  intestine,  this 
being  greatest  in  the  cecum  and  descending  colon,  throughout 
which  ulcers  may  be  found  ;  these  ulcers  may  be  single  or  mul- 
tiple, and  are  of  varying  depth.  In  many  instances  catarrhal 
pneumonia  will  complicate  the  later  stages  of  the  disease,  and 
in  these  cases  solidification  will  be  found  at  the  bases  of  the 
lungs.  According  to  Ashby  and  Wright,  a  microscopic  exami- 
nation of  the  mucous  membrane  of  the  intestines  shows  a  gen- 
eral distention  of  the  network  of  their  capillaries  and  an  exuda- 
tion of  leukocytes.  This  condition  exists  in  the  mucous  mem- 
brane itself,  the  submucosa,  the  villi,  and  between  the  tubules 
and  crypts  of  Lieberkiihn.  The  central  portions  of  the  solitary 
glands  are  softened,  or  the  softened  portion  having  been  dis- 


2O2  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

charged,  the  remains  of  the  glands  appear  as  sharply  cut 
ulcers. 

Examination  of  the  brain  shows  no  specific  lesion  ;  occasion- 
ally the  sinuses  are  found  distended  with  blood,  or,  on  the  other 
hand,  a  condition  of  cerebral  anemia  may  exist.  Ashby  and 
Wright  mention  one  case  in  which  meningitis  was  present,  but 
these  instances  are  extremely  rare. 

Symptoms. — No  matter  how  the  poison  enters  the  system, 
the  symptoms  of  acute  milk  infection  are  nearly  always  the  same. 
Occasionally  a  mild  diarrhea  may  precede  by  a  few  days  the 
sudden  onset  of  the  acute  indications.  During  this  time  the 
stools  are  more  frequent  than  normal  and  are  green.  There  may 
be  some  vomiting  after  taking  food.  It  is  very  questionable, 
however,  whether  this  preliminary  diarrhea  is  part  of  the  true 
attack  of  cholera  infantum.  Very  frequently  the  disease  begins 
suddenly  at  a  time  when  the  child  is  in  perfect  health.  The  first 
symptoms  are,  then,  vomiting  and  purging.  The  vomiting  is 
intense  and  continuous.  The  vomited  matter  is  first  composed 
of  the  gastric  contents,  later  of  watery  detritus,  and,  finally,  after 
there  is  nothing  left  in  the  stomach  to  be  thrown  off,  the  attempts 
at  vomiting  continue.  The  child  has  nausea  of  the  most  intense 
character.  The  vomiting  is  increased  by  the  taking  of  food  or 
drink — in  fact,  anything  put  into  the  stomach  is  immediately 
expelled.  During  these  paroxysms  the  child  becomes  pale,  the 
lips  are  blue,  a  dark  line  is  seen  around  the  mouth,  and  the 
entire  body  is  covered  with  cold,  clammy  sweat.  The  evacua- 
tions of  the  bowels  occur  more  and  more  frequently,  until  they 
are  practically  continuous.  Their  character  changes  with  great 
rapidity  from  the  normal  yellow  movement  of  the  infant  to  a 
thin,  green,  spinach-like  discharge  (decomposed  mucus),  and 
finally  an  almost  continual  expulsion  of  large  quantities  of  water 
mixed  with  shreds  of  mucus,  which  give  them  somewhat  the 
appearance  of  rice-water ;  these  discharges  have  a  characteristic 
musty  odor,  are  acid  in  reaction,  and  are  composed  of  serum 
mixed  with  epithelial  cells  and  swarming  with  bacteria.  The  abdo- 
men in  the  earlier  stages  of  the  disease  may  be  slightly  distended 
and  soft,  but  as  the  diarrhea  continues  it  becomes  retracted.  A 
marked  difference  exists  in  the  temperature  of  the  surface  of  the 
body  and  of  the  interior.  Occasionally  during  the  first  few  hours 
the  surface  temperature  may  be  above  98.6°  F.  (37°  C),  but  in 
the  majority  of  cases  it  does  not  rise  above  the  normal  point. 
In  the  algid  state  of  extreme  depression  it  is  distinctly  subnormal. 
The  rectal  temperature  will  be  found  to  be  anywhere  between 
103°  and  107°  F.  (39.4°  to  41.6°  C.).  The  average  duration  of 


ACUTE    MILK    INFECTION. 

the  disease  is  from  one  to  three  days,  although  we  have  seen 
cases  in  which  the  entire  attack,  from  the  first  symptoms  until 
the  death  of  the  child,  has  lasted  but  six  hours.  The  loss  of 
flesh  is  appalling,  the  child  frequently  changing  in  the  course  of 
a  few  hours  from  a  rosy,  plump  baby  to  a  mere  skeleton  covered 
with  skin.  There  is  probably  no  other  disease,  with  the  excep- 
tion of  Asiatic  cholera,  in  which  the  emaciation  is  so  extreme  in 
so  short  a  time.  This  rapid  decline  in  bodily  weight  is  due  to 
destructive  loss  of  fluids.  As  the  disease  progresses  the  respi- 
rations become  shallow  and  jerky,  and  the  child  passes  into  a 
state  of  coma,  convulsions,  or,  rarely,  delirium.  It  is  not  unusual 
to  find  a  short  interval  during  which  there  is  a  lull  in  the  symp- 
toms. At  this  point  in  the  disease  the  child  may  begin  to  im- 
prove, but  much  more  commonly  this  interval  is  quickly  followed 
by  an  increase  in  the  symptoms  of  profound  nervous  depression, 
the  child  passing  into  a  state  of  coma,  followed  by  death.  When 
the  amount  of  poison  is  originally  very  great,  the  patient  may 
become  comatose  in  a  very  few  hours.  These  cases  are  practi- 
cally hopeless.  During  the  entire  attack  the  thirst  is  extreme. 

Diagnosis. — The  diagnosis  of  cholera  infantum  should  not  be 
difficult,  the  history  of  the  disease  and  the  intensely  acute  onset 
resembling  no  other  intestinal  affection  except  Asiatic  cholera. 
When  the  latter  disease  is  epidemic,  a  bacteriologic  examination 
is  the  only  method  of  differential  diagnosis.  Occasionally  it  may 
be  confounded  with  thermic  fever  (sunstroke),  but  the  discharges 
of  cholera  infantum  are  continuous,  and  it  lacks  the  high  tem- 
perature which  is  always  found  in  sunstroke. 

Prognosis. — The  prognosis  of  cholera  infantum  is  always 
grave.  If,  while  the  attack  lasts,  the  child  is  fed  on  milk,  the 
disease  is  nearly  always  fatal.  The  prognosis  naturally  is  more 
favorable  in  strong,  healthy  children  than  in  those  who  are 
weakly.  A  long-continued  previous  diet  of  artificial  foods  seems 
to  make  the  prognosis  less  favorable.  The  symptoms  on  which 
to  base  a  favorable  prognosis  are  a  slight  attack  and  rapid  and 
steady  decrease  in  the  vomiting  and  diarrhea.  The  absence  of 
symptoms  of  profound  nervous  depression  are  favorable.  The 
physician,  however,  should  not  expect  to  save  the  lives  of  the 
majority  of  the  infants  affected  with  this  disease. 

Prophylactic  Treatment. — The  prophylactic  treatment  of 
acute  milk  infection  consists  in  the  careful  attention  to  the  clean- 
liness of  the  infant's  food  and  the  articles  used  in  the  nursing. 
If  the  child  is  fed  from  the  breast,  the  nipples  of  the  mother  or 
nurse  should  be  washed  before  and  after  nursing  according  to 
the  rules  laid  down  in  the  chapter  on  hygiene  and  diet.  If  fed 


2O4  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

from  the  bottle,  the  greatest  care  should  be  exercised,  particu- 
larly in  summer,  in  scalding  and  thoroughly  cleaning  the  nurs- 
ing-bottle after  each  nursing.  At  all  times,  and  especially  during 
the  summer  months,  any  small  digestive  disturbance  which  may 
make  its  appearance  must  receive  careful  attention,  and  should  a 
slight  attack  of  diarrhea  appear,  milk  must  be  stopped  unless 
the  child  is  nursing  from  the  breast,  and  even  then  it  is  better 
to  diminish  the  number  of  nursings  and  substitute  definite 
quantities  of  beef  broth  or  albumin-water  for  several  hours. 
Very  often  at  this  time  a  dram  or  two  of  castor  oil,  with  small 
doses  of  calomel  repeated  once  or  twice  during  the  twenty-four 
hours,  will  end  the  trouble. 

Treatment  of  the  Attack. — The  first  indication  in  the  treat- 
ment of  milk  infection — the  one  that  is  of  the  greatest  importance 
— is  to  remove  the  source  of  the  poison  ;  hence  all  milk  must  be 
stopped,  nor  should  any  food  containing  it  be  given  to  the  child. 
Sterilization  or  Pasteurization  of  milk  does  not  render  it  a  proper 
food  in  this  disease.  The  child  should  receive  no  food  at  all  for 
from  eight  to  twelve  hours — indeed,  in  some  instances  as  long  as 
twenty-four  hours — after  the  beginning  of  the  attack.  During 
this  time  small  quantities  of  about  half  an  ounce  of  cold  sterilized 
water  should  be  given  at  regular  intervals,  and  in  order  to  aid  in 
stimulating  the  patient  brandy 'or  whisky  may  be  added  to  the 
water.  In  some  cases  we  have  had  favorable  results  from 
moderately  large  doses  of  alcoholic  stimulants,  giving  say  a  tea- 
spoonful  of  good  brandy  freely  diluted  in  cold  sterilized  water 
every  hour  or  even  oftener  during  the  period  of  collapse.  The 
second  indication  is  to  aid  nature  in  freeing  the  system  of  the 
poison  which  is  already  in  it.  For  this  purpose  washing  out 
the  stomach  and  intestines  gives  excellent  results.  These  irri- 
gations must  be  repeated  frequently.  The  water  must  be  steri- 
lized and  may  be  used  plain,  or,  what  is  probably  better,  should 
be  medicated  by  the  use  of  calomel  and  bismuth,  or  any  of  the  salts 
of  the  latter,  particularly  the  subnitrate  and  subgallate,  or  a  I  per 
cent,  solution  of  sodium  chlorid.  The  results  of  these  irrigations 
are  twofold :  they  not  only  aid  in  clearing  the  intestines  of  the 
poisonous  materials,  but  also,  by  the  absorption  of  at  least  a 
quantity  of  the  solution  injected,  assist  in  keeping  up  the  amount 
of  water  which  the  system  needs  and  of  which  it  has  lost  such 
large  quantities  by  the  continuous  discharge  from  the  bowels.  In 
order  to  maintain  external  bodily  heat,  the  child  should  be  placed 
in  a  hot  bath,  the  temperature  of  which  is  to  be  increased  from 
95°  F.  (35°  C.)  to  110°  F.  (43.3°  C.)  ;  the  stimulating  effect  of 
this  bath  is  increased  by  the  addition  of  mustard.  In  some  cases 


ACUTE    MILK    INFECTION.  2O5 

placing  the  child  in  a  hot  pack  at  about  1 10°  F.  (43.3°  C.)  will 
cause  reaction. 

The  stomach  can  best  be  irrigated  with  water  containing  I 
per  cent,  of  sodium  chlorid,  after  which  from  three  to  five  grains 
of  calomel  may  be  similarly  administered,  as  advised  by  Vaughn. 
The  irrigation  of  the  stomach  and  intestines  should  be  repeated 
as  long  as  the  vomiting  and  purging  continue.  In  the  treatment 
of  cholera  infantum  drugs  must  hold  a  second  place  ;  neverthe- 
less, a  few  are  useful.  They  may  be  administered  by  mouth  or 
rectum.  In  order  to  somewhat  control  the  large  watery  move- 
ments, good  results  sometimes  follow  the  injection  into  the  bowels 
of  a  pint  of  cool  sterilized  water  containing  from  fifteen  to  thirty 
grains  of  tannic  or  gallic  acid.  This  injection  should  immedi- 
ately follow  a  copious  enema  of  sterilized  salt  solution.  When 
the  system  has  suffered  a  great  loss  of  water,  as  in  fact  it  always 
does  in  this  disease,  and  a  considerable  degree  of  collapse  makes 
its  appearance,  subcutaneous  injections  of  salt  solution  are  indi- 
cated. For  the  relief  of  vomiting,  and  also  as  a  cardiac  stimu- 
lant, hypodermic  injections  of  y^-  of  a  grain  of  morphin  combined 
with  -g-^7  of  a  grain  of  atropin  may  be  used.  Digitalis  or  digitalin 
may  also  be  used  as  a  more  permanent  cardiac  stimulant.  Minute 
doses  of  the  arsenite  of  copper,  carbolic  acid  with  glycerin  in  drop 
doses,  minute  quantities  of  bichlorid  of  mercury,  and  many  of 
the  coal-tar  products  have  been  brought  forward  as  useful  reme- 
dies, and  undoubtedly  do  have  some  effect,  but  all  of  these  must 
take  second  place  to  the  mechanical  means  of  treatment  by  the 
washing  out  of  the  intestines  and  stomach.  As  an  intestinal  an- 
tiseptic salicylate  of  soda  has  been  recommended  by  A.  Jacobi 
and  Emmet  Holt.  The  subnitrate  or  subgallate  of  bismuth,  in 
doses  of  from  ten  grains  to  a  dram,  the  smaller  doses  to  be  adminis- 
tered by  the  mouth  and  the  larger  by  the  intestines,  is  certainly 
of  some  use.  Although  opium  in  the  early  stages  of  cholera 
infantum  is  worse  than  useless,  yet  occasionally,  when  the  disease 
has  lasted  for  some  days,  rectal  injections  of  four  or  five  drops  of 
the  tincture  in  warm  starch  water  will  soothe  and  diminish  the 
irritability  of  the  intestines.  Small  and  frequently  repeated  doses 
of  calomel  (^  to  -£$  of  a  grain  given  every  fifteen  minutes  until 
two  or  three  grains  have  been  administered)  have,  in  the  authors' 
hands,  given  fully  as  good  results  as  any  other  drug  used  in  the 
treatment  of  this  disease.  When  the  surface  temperature  is  high, 
— that  is,  above  103°  F.  (39.4°  C.), — an  ice-cap  may  be  placed  on 
the  child's  head,  or  the  fever  may  be  reduced  by  frequently 
sponging  the  body  with  tepid  water,  followed  by  friction.  No 
antipyretic  drugs  should  be  given,  as  they  do  more  harm  than 


2O6  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

good.  When  the  surface  temperature  sinks  below  normal,  stimu- 
lants in  the  form  of  a  hot  pack  or  hot  bath  should  be  employed, 
as  has  been  before  stated.  Stimulating  drugs,  such  as  alcohol, 
aromatic  spirits  of  ammonia,  musk,  camphor,  or  other  agents  of 
this  class,  may  also  be  employed.  After  the  vomiting  has 
become  less  frequent,  the  child  may  be  given  small  quantities  of 
nourishment  in  the  form  of  panopeptone,  beef  peptonoids,  freshly 
prepared  beef-juice,  scraped  beef,  or  albumin-water.  Starch 
water,  arrow-root,  any  food  containing  starch,  advised  by  some 
as  a  preliminary  diet  after  cholera  infantum,  have  not  met  with  very 
much  success  in  the  authors'  hands.  Our  own  preference  is  for 
albumin-water,  some  form  of  thin  beef-extract,  or  light  broths. 

Not  until  the  child  has  passed  several  days  without  any  return 
of  the  symptoms  of  the  disease  should  milk  be  used  as  an  article 
of  food  ;  it  should  then  be  carefully  modified,  either  at  home 
or,  better,  at  some  good  milk  laboratory.  Great  care  must  be 
taken  as  to  the  cleanliness  of  the  food,  the  bottle,  and  the  nipple. 
When  the  child  has  been  fed  by  the  breast  at  the  time  of  taking 
the  disease,  the  same  rules  must  be  adhered  to  as  when  it  is  fed 
by  the  bottle. 

SUBACUTE   MILK    INFECTION. 

Synonyms. — SUMMER  DIARRHEA  ;  INFECTIOUS  DIARRHEA  ;  ENTERO- 
COLITIS  ;   SUMMER  COMPLAINT. 

Subacute  milk  infection  is  a  form  of  gastro-intestinal  catarrh 
originating  from  the  action  of  poisons  generated  by  the  growth 
and  multiplication  of  bacteria  in  the  milk  from  which  the  child  is 
fed.  The  poisons  are  either  bacterial  or  chemic,  are  not  so  intense 
as  those  producing  the  acute  form  of  the  disease,  but  are  more 
diffuse.  The  symptoms  not  being  so  severe  as  to  cause  alarm  in 
the  beginning  of  the  disease,  the  patient  is  too  often  kept  upon 
the  same  diet  of  infected  milk,  and  thus  continually  receives  a 
fresh  supply  of  poisonous  material.  The  number  of  deaths  result- 
ing from  this  disease  is  yearly  much  greater  than  from  the  acute 
form.  It  is  almost  entirely  a  disease  of  the  summer  months,  and 
during  this  time  its  ravages  are  fearful.  The  number  of  its 
victims  increases  as  soon  as  the  temperature  rises  above  60°  or 
70°  F.  (15.6°  or  21.1°  C.),  and  decreases  correspondingly  with 
each  cooler  period.  It  is  more  prevalent  in  hot,  damp  weather 
than  when  the  air  is  dry.  Like  the  acute  form,  it  is  worse  among 
the  poorer  classes  of  our  great  cities.  Just  in  proportion  as  the 
milk  given  a  child  is  pure  and  the  patient's  hygienic  surroundings 
are  good,  just  in  so  much  is  the  danger  of  this  disease  decreased. 


p--*si-OrR*rJF 

SUBACUTE    MILK    INFECl*l66il//:  [f  r  "Zftf 

Causes. — Subacute  milk  infection,  as  has  been  before  stated^/ 


I-IG.  23. — SUBACUTE  MILK  INFECTION. 

(From  patient  in  the  Department  of  Obstetrics  and  Diseases  of  Infancy 
Polyclinic  Hospital,  Philadelphia.) 


is  caused  by  bacteria,  the  poisons  generated  by  which  have  been 


-e  X****  :,3iicB 
*_. 

2O8  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

VVA  !,.-, 

taken  into  the  system  in  milk.  The  subacute  form  may  also  be 
but  a  simple  continuation  of  a  mild  attack  of  acute  milk  infection 
for  a  period  beyond  the  ordinary  duration  of  the  latter  disease. 

Pathology. — Microscopic  examination  of  the  stools  will  show 
that  they  contain  epithelial  cells,  crystalline  formations,  occasion- 
ally blood,  and  in  older  children  fibers  of  meat.  In  one  case 
recorded  by  J.  Lewis  Smith,  he  states  that  he  observed  particles 
resembling  three  or  four  crypts  of  Lieberkuhn  united  and  prob- 
ably thrown  off  as  the  result  of  ulceration.  Owing  to  the  con- 
tinual irritation  of  the  intestines,  due  to  the  inflammation  set  up 
by  bacteria  and  their  poisons  and  also  very  probably  by  the 
mechanical  presence  of  the  bacteria  themselves,  inflammation  is 
set  up,  resulting  in  ulcerations  here  and  there  along  the  ileum 
and  colon.  The  greatest  amount  of  inflammatory  change  is 
generally  found  in  the  colon,  and  here  ulcers  may  be  formed 
either  singly  or  in  groups.  They  may  be  seen  in  any  part  of 
this  division  of  the  large  intestine.  The  upper  parts  of  the 
duodenum  and  jejunum  are  generally  free  from  these  inflam- 
matory changes. 

Symptoms. — The  disease  usually  begins  with  a  gradually 
increasing  diarrhea  and  some  vomiting,  both  of  whu'ch  are  in- 
creased after  taking  nourishment.  The  vomiting,  however,  does 
not  always  appear,  and  when  it  does,  it  is  in  the  more  acute 
form  of  the  disease.  The  symptoms  may  develop  immediately 
after  nursing,  especially  when  the  child  is  fed  from  the  bottle,  or 
may  appear  after  an  interval  of  cessation  following  an  attack  of 
acute  milk  infection.  In  this  latter  instance  it  almost  invariably 
shows  that  the  child  has  been  returned  too  soon  to  a  milk  diet. 
As  the  bowel  movements  increase  in  frequency  they  will  contain 
large  quantities  of  mucus,  undigested  food,  especially  coagulated 
casein,  and  masses  of  fat.  Each  evacuation  of  the  bowels  is  pre- 
ceded and  followed  by  the  expulsion  of  gas.  The  color  of  the 
stools  is  at  first  yellow  or  brown,  but  soon  changes  to  greenish 
or  greenish  yellow.  Occasionally  they  are  at  first  of  a  greenish 
color.  Anorexia  is  present,  and  the  child  loses  flesh  and  strength 
from  failure  of  its  nutritive  powers.  The  tongue  is  coated  with 
a  whitish  or  grayish-white  coat.  The  temperature  is  always  in- 
creased during  this  disease,  and  its  character  is  such  that,  except 
for  the  irregular  time  of  the  daily  onset,  it  might  be  confounded 
with  the  fever  of  tuberculosis.  The  temperature  is  seldom  above 
102°  or  103°  F.  (38.9°  or  39.4°  C),  and  may  be  so  slight  as  to 
escape  detection.  During  the  attack  the  child  is  irritable,  whining 
and  crying  in  its  sleep.  After  each  bowel  movement  it  generally 
enjoys  a  short  period  of  rest.  A  considerable  amount  of  flatu- 


SUBACUTE  MILK  INFECTION.  209 

lence  is  present,  and  this  increases  the  amount  of  nervous  dis- 
turbance. From  the  frequent  irritating  discharge  from  the  bowels 
the  entire  buttocks  and  often  the  greater  part  of  the  posterior 
surfaces  of  the  thighs  are  covered  with  an  erythema.  Enlarge- 
ment of  the  lymphatics  of  the  groin,  throat,  or  neck  is  not  infre- 
quent, and  although  this  is  not  a  serious  complication,  yet  occa- 
sionally the  glands  may  suppurate  and  cause  trouble.  Otitis 
media  is  an  occasional  complication.  Various  forms  of  irregular 
skin  eruptions  of  an  eczematous  or  erythematous  character  are 
often  seen,  and  boils  are  a  common  complication.  Aphthous 
stomatitis  is  a  very  frequent  and  painful  accompaniment. 

Bronchopneumonia  and  meningitis  of  infective  origin  and 
middle-ear  disease  from  the  same  cause  are  not  infrequent  com- 
plications. Death  may  occur  from  hypostatic  congestion.  Other 
diseases,  such  as  nephritis  or  tuberculosis,  not  infrequently  appear 
later  in  feeble  children. 

Diagnosis. — The  diagnosis  should  be  founded  on  the  symp- 
toms and  history  of  the  case.  There  are  really  very  few  diseases 
with  which  subacute  milk  infection  can  be  confounded.  From 
cholera  infantum  it  is  to  be  distinguished  by  the  more  gradual 
onset,  its  milder  symptoms,  and  the  absence  of  the  characteristic 
large,  watery  stools  found  in  the  acute  form  of  the  disease  ;  the 
vomiting  and  prostration  are  not  so  great,  nor  is  the  temperature 
so  high  as  in  cholera  infantum.  From  the  various  forms  of 
obstructions  of  the  intestines  it  is  to  be  diagnosticated  by  the 
fever,  the  gradual  onset,  and  the  absence  of  the  extreme  tenes- 
mus,  pain,  and  stercoraceous  vomiting,  none  of  which  appears  in 
subacute  milk  infection. 

Prognosis. — The  prognosis  depends  on  the  strength  and 
vitality  of  the  child,  on  its  surroundings,  and  on  the  capabilities 
of  those  who  attend  its  wants  to  give  proper  food  and  general 
care  ;  the  outlook  for  the  recovery  of  feeble  children — those  who 
are/ed  on  all  varieties  of  foods  and  badly  prepared  milk  and  live 
amid  unhygienic  surroundings — is  unfavorable.  On  the  contrary, 
when  the  patient  can  be  taken  where  good  pure  air  can  be 
breathed,  especially  the  air  of  the  seashore  or  mountains,  and 
fed  on  properly  prepared  food,  the  prognosis  is  fairly  good.  The 
duration  of  the  attack  has  also  a  considerable  influence  on  the 
prognosis.  The  sooner  the  patient  has  the  care  of  a  physician, 
the  better  the  prognosis. 

Treatment. — As  in  all  other  forms  of  intestinal  disease  caused 
by  the  presence  of  bacteria  and  their  ptomains,  the  careful  regu- 
lation of  the  diet  is  the  most  important  consideration.  So  long 
as  milk,  which  is  one  of  the  best  of  all  culture-media  for  bacteria, 


2IO  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

is  given  the  child,  just  so  long  will  the  disease  continue.  The 
removal  of  this  article  of  diet  is  as  much  demanded  in  subacute 
milk  infection  as  it  is  in  the  acute  form.  These  children,  then, 
should  be  relieved  entirely  from  a  milk  diet,  and  placed  upon 
freshly  prepared  animal  broths  or  liquid  peptonoids.  These  should 
be  given  at  regular  intervals  of  three  or  four  hours,  for  regularity 
of  feeding  is  of  nearly  as  much  importance  as  the  items  of  diet 
upon  which  the  child  is  fed.  Albumin-water,  boiled  rice,  or  arrow- 
root may  occasionally  be  substituted  with  benefit  for  the  animal 
broths.  All  the  foregoing  articles  should  be  freshly  made.  The 
child  must  not  be  placed  on  a  milk  diet  until  the  disease  is  well 
under  control,  the  discharges  from  the  bowels  have  become  normal 
in  color  and  frequency,  and  vomiting  has  ceased.  The  patient,  if 
living  in  a  crowded  tenement,  should,  if  possible,  be  taken  to  the 
country,  or  at  least  where  it  can  breathe  pure  air.  Directions 
should  be  given  the  mother  or  nurse  not  to  hold  it  in  the  arms 
any  more  than  is  necessaiy,  but  to  let  it  lie  on  a  moderately  hard 
mattress  where  it  can  have  the  air  from  an  open  window,  or, 
better,  on  a  hard  pillow  in  its  coach  in  a  cool  place  in  the  yard, 
or  on  the  street  after  the  sun  goes  down.  Instruction  should  be 
given  not  to  allow  the  child  to  have  the  nursing-bottle  at  its  lips 
all  the  time  while  lying  in  the  coach  or  on  the  bed,  but  it  should 
be  fed  only  at  regular  intervals,  and  between  these  should  receive 
nothing  in  the  way  of  nourishment.  It  should  have  at  least  one 
bath  daily,  and  the  diapers  should  be  thoroughly  washed  and 
boiled.  They  should  be  changed  frequently.  It  is  also  of  great 
importance  that  the  child  drink  plentifully  of  water,  providing  it 
be  sterilized  and  given  in  small  quantities  at  a  time.  A  few  drops 
of  good  whisky  or  brandy  added  to  each  drink  is  often  helpful. 

Irrigation  of  the  intestines  is  of  as  much  importance  in  the 
treatment  of  this  disease  as  in  other  forms  of  infective  diarrhea. 
Lavage  of  the  stomach  is  indicated  when  the  mucous  membrane 
of  this  organ  seems  to  be  involved.  When  the  patient  is  seen  at 
the  beginning  of  the  attack,  the  greatest  benefit  can  be  derived 
from  the  giving  of  a  laxative,  such  as  moderate  doses  of  calomel, 
with  castor  oil,  and  possibly  a  few  drops  of  paregoric  to  prevent 
griping.  When  we  see  the  patient  later  in  the  disease,  small 
doses  of  calomel,  combined  with  powdered  ipecac  and  powdered 
rhubarb,  are  probably  about  as  useful  remedies  as  we  can  give. 
The  various  salts  of  bismuth  and  other  intestinal  antiseptics  are 
of  some  use,  but  too  much  reliance  must  not  be  placed  upon 
them.  Large  doses  of  paregoric,  either  alone  or  combined  with 
chalk  mixture,  or  the  various  diarrhea  preparations  should  not 
be  given  at  all.  After  the  disease  is  thoroughly  under  control 


ILEOCOLITIS.  2  I  I 

and  the  digestion  remains  weak,  such  remedies  as  nux  vomica, 
arsenic,  particularly  in  the  form  of  Fowler's  solution,  nitro- 
muriatic  acid,  and  others  of  this  class  may  be  used  with  benefit. 
Iron  may  be  employed  if  anemia  is  present.  Cod-liver  oil  has 
been  recommended,  and  is  undoubtedly  of  use,  but  when  the 
digestion  is  weak,  as  it  generally  is,  it  is  best  employed  in  the 
form  of  inunctions. 


ILEOCOLITIS. 

Ileocolitis,  the  so-called  dysentery  or  dysenteric  diarrhea,  is  an 
inflammation  of  the  mucous  membrane  of  the  lower  part  of  the 
large  intestine  (colon  and  rectum),  accompanied  usually  by  the 
formation  of  patches  of  ulceration,  which  in  number  may  be 
single  or  multiple.  The  disease  may  be  acute  or  chronic,  and 
while  usually  sporadic,  sometimes  appears  in  an  epidemic  form. 

Causes.  —  The  same  causes  which  in  children  produce  other 
forms  of  intestinal  inflammation  are  also  active  in  the  etiology  of 
dysentery.  Improper  feeding  with  bad  milk,  improper  hygiene, 
crowding  in  poorly  ventilated,  filthy  tenements,  and  general  lack 
of  care  are  all  fruitful  factors  in  the  causation  of  dysentery. 
The  disease  is  more  frequent  among  the  poorer  classes,  but  it 
will  occur  in  any  condition  of  life  where  children  are  not  given 
the  proper  kinds  of  food.  As  a  rule,  the  disease  is  more  com- 
mon in  cities  and  in  the  "slums"  of  cities  than  in  the  healthy 
districts  of  the  latter  or  in  the  country.  Predisposing  factors  in 
the  etiology  of  the  disease  are  all  lowered  states  of  vitality,  such 
as  those  produced  by  rickets,  syphilis,  tuberculosis,  etc.  The 
disease  is  probably  always  bacterial  in  origin,  but,  with  the  ex- 
ception of  the  true  diphtheric  and  so-called  amebic  forms,  we 
can  not  identify  the  exact  form  of  germ  producing  it.  The  path 
of  infection  in  the  majority  of  cases  is  probably  through  the  food 
or  drinking-water.  The  disease  occasionally  appears  in  epi- 
demics, the  cause  of  which  is  decidedly  obscure,  unless,  like 
typhoid,  it  be  carried  by  water,  or  air  infected  from  a  previously 
existing  case. 

The  croupous  or  diphtheric  form  may  result  from  diphtheria  in 
any  part  of  the  air-passages,  or  it  may  appear  as  a  primary  infec- 
tion of  the  entire  colon  or  lower  part  of  the  ileum  or  cecum.  A 
rare  disease,  known  as  amebic  dysentery,  has  been  described  by 
Osier,  Holt,  Councilman,  and  others.  It  is  caused  by  the 
amceba  coli  (Losch)  or  amceba  dysenteriae  (Councilman  and 
Lafleur).  Osier  describes  the  ameba  as  follows  :  "  It  is  a  uni- 
cellular, protoplasmic,  motile  organism  from  ten  to  twenty 


212  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

micromillimeters  in  diameter,  and  consists  of  a  clear  outer  zone 
(ectosarc)  and  a  granular  inner  zone  (endosarc)  containing  a 
nucleus  and  one  or  more  vacuoles."  This  disease  is  seldom  seen 
in  this  country,  but  it  is  very  frequent  in  the  tropics.  The 
source  of  infection  is  probably  drinking-water. 

Pathology. — The  pathology  of  ileocolitis  is  considerably 
simplified  if  we  remember  that  this  disease  is  in  many  cases 
simply  a  continuation  downward  along  the  colon  of  the  same 
inflammatory  process  as  that  producing  an  attack  of  enteroco- 
litis  ;  in  fact,  in  the  authors'  opinion,  the  chronic  form  of  the  so- 
called  catarrhal  dysentery  usually  begins  in  this  way.  We  find 
the  mucous  membrane  of  the  colon  and  rectum  congested  to  a 
very  marked  degree,  or  occasionally  the  inflammatory  condition 
may  extend  upward  as  far  as  the  ileum,  or  in  bad  cases  the 
whole  large  intestine  may  be  involved.  The  mucous  membrane 
is  intensely  hyperemic,  and  this  condition  may  be  limited  to  cir- 
cumscribed areas  or  may  be  general.  Small  hemorrhages  some- 
times take  place  into  the  mucosa  or  submucosa.  The  mucous 
membrane  in  the  parts  affected  is  covered  with  a  thick,  sticky 
mucus,  which  in  some  cases  is  extremely  adhesive  and  hard  to 
remove.  The  color  of  the  mucous  membrane  varies  from  bright 
red  to  purple,  and  is  seldom  uniform  in  color.  The  solitary 
lymph-follicles  along  the  colon  are  swollen,  and  each  is  sur- 
rounded by  an  area  of  hyperemia,  and  in  many  cases  the 
breaking-down  of  these  glands  occurs  later,  producing  an  ulcer. 
These  ulcers  may  be  either  single  or  multiple,  and  often  extend 
considerably  in  size  after  they  first  begin,  or  in  some  instances 
two  or  more  may  coalesce,  forming  one  large,  irregular,  ulcera- 
tive  patch,  which  may  simply  be  confined  to  the  mucous  mem- 
brane, or,  proceeding  deeper,  may  involve  the  submucosa  or  even 
perforate  the  entire  wall  of  the  intestine.  The  mesenteric  glands 
are  enlarged  and  softened.  The  liver  is  usually  congested, 
although  anemia  of  this  organ  may  be  present,  as  in  the  case 
recorded  by  Busey.  Suppuration  of  the  kidney  may  also  occur. 
Examination  of  the  brain  will  not  infrequently  show  one  or  more 
thrombi  in  the  sinuses  of  the  dura  mater.  In  other  cases  in- 
flammation of  the  brain  structure  or,  on  the  contrary,  cerebral 
anemia  may  be  found. 

Croupous  or  diphtheric  dysentery  is  the  name  given  to  a  variety 
of  the  disease  which  is  associated  with  the  formation  of  diph- 
theric ulcers  occurring  in  the  same  part  of  the  intestine  as  do 
those  of  the  catarrhal  form.  These  patches  are  covered  with  a 
tenacious,  grayish-white  membrane  which,  when  removed,  leaves 
a  bleeding  ulcer.  The  membrane  is  composed  of  fibrin,  necrotic 


ILEOCOLITIS.  213 

cells,  and  blood-corpuscles.  Both  the  mucosa  and  submucosa 
undergo  considerable  infiltration  and  thickening.  Between  the 
patches  the  mucous  membrane  is  congested  and  more  or  less 
roughened.  The  pathology  of  the  amebic  form  is  as  follows  : 

The  lesions  are  principally  found  in  the  lower  portion  of  the 
ileum  and  colon,  and  consist  of  small  elevations  appearing  along 
the  mucous  membrane  and  associated  with  infiltration.  The 
ulcer  first  begins  as  a  small  papule,  the  upper  part  of  which 
sloughs  off,  leaving  a  grayish-yellow  ulcerating  surface.  Amebae 
are  found  in  the  tissues  in  and  around  the  ulcers,  in  the  lymphatic 
spaces,  and  occasionally  in  the  blood-vessels.  Multiple  abscesses 
arising  from  the  same  cause  are  usually  found  throughout  the 
liver  and  occasionally  in  the  lungs. 

Symptoms. — In  the  so-called  acute  catarrhal  form  of  ileo- 
colitis  the  attack  begins  suddenly  with  diarrhea,  accompanied  by 
great  tenesmus  and  followed  by  chills  and  a  moderate  rise  of 
temperature.  As  the  disease  progresses  the  patient  rapidly  loses 
strength,  the  pulse  becomes  rapid  and  feeble,  and  the  face  pre- 
sents a  peculiar  pinched,  pale,  and  anxious  expression.  The 
weakness  is  increased  after  each  evacuation  of  the  bowels,  the 
number  of  passages  soon  becoming  very  numerous.  The  stools 
at  first  contain  ordinary  fecal  matter,  but  rapidly  become  smaller 
in  quantity,  more  liquid,  and  mixed  with  mucus,  blood,  or  pus, 
and  in  advanced  cases  contain  shreds  which  are  sometimes  de- 
scribed as  resembling  the  washings  of  raw  meat.  This  symptom 
is  generally  associated  with  considerable  ulceration.  The  urine 
is  scanty  and  high  colored,  and  in  bad  cases  there  may  be  abso- 
lute suppression.  Vesical  tenesmus  is  a  common  symptom. 
The  abdomen  is  usually  swollen  and  tympanitic.  The  tongue  is 
covered  with  a  brown  fur  along  the  center,  its  margin  being  red. 
Vomiting  may  occur,  but  is  more  generally  seen  in  the  earlier 
stages  of  the  disease  ;  it  is  usually  not  severe.  If  the  case  pro- 
gresses toward  a  fatal  issue,  the  respirations  become  irregular  and 
sighing,  the  eyes  are  partially  closed,  and  the  pupils  are  dilated. 
Not  infrequently  the  child  will  die  in  a  state  of  absolute  collapse. 
Prolapse  of  the  rectum  frequently  occurs,  and  is  caused  by  the 
great  state  of  relaxation  in  this  part  of  the  bowels.  In  the 
later  stages  of  the  disease  convulsions  are  common,  and  the 
child  may  die  during  an  attack.  Microscopic  examination  of  the 
stool  shows  large  quantities  of  mucus,  with  epithelial  cells  of 
different  types  usually  found  in  the  lower  bowel,  blood-corpuscles 
and  pus-corpuscles,  fat,  and  a  large  number  of  bacteria.  In  the 
so-called  diphtheric  form  of  the  disease  the  symptoms  are  about 
the  same  as  before  described,  except  that  they  are  more  intense. 


214  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

The  amebic  form  is  characterized  by  a  series  of  symptoms  not 
unlike  those  of  the  catarrhal  and  diphtheric  varieties,  but  are  less 
severe  than  the  latter.  Large  numbers  of  the  amoeba  coli  will 
be  found  in  the  stools  during  the  diarrheal  attack  and  will  serve 
to  verify  the  diagnosis. 

Diagnosis. — The  diagnosis  of  acute  cases  of  the  catarrhal 
form  must  be  made  by  the  character  of  the  stools  and  by  the 
general  symptoms.  The  following  are  a  few  of  the  other  types 
of  intestinal  catarrh  from  which  it  must  be  differentiated  :  From 
acute  milk  infection  it  is  to  be  differentiated  by  its  less  acute  on- 
set, less  amount  of  vomiting,  and  higher  temperature.  In  dys- 
entery the  stools  are  smaller  in  quantity,  contain  blood,  mucus, 
and  pus,  and  have  less  odor.  In  ileocolitis  there  are  not  the 
general  symptoms  of  acute  poisoning  which  are  always  present 
in  milk  infection.  From  other  forms  of  gastric  or  enteric  catarrh 
dysentery  can  be  diagnosticated  by  its  smaller  stools,  intense 
tenesmus,  and  the  amount  of  prostration  following  each  evacua- 
tion. The  stools  of  dysentery  are  distinctly  bloody,  and  there 
are  less  of  mucus  and  water  than  in  the  stools  of  other  forms 
of  enteric  catarrh.  In  dysentery  the  stools  lack  the  greenish  or 
greenish-yellow  color  of  those  seen  in  other  forms  of  "inflamma- 
tion affecting  the  upper  parts  of  the  intestines.  Chronic  catarrhal 
ileocolitis  might  possibly  in  some  instances  be  confounded  with 
mucous  disease ;  the  latter  is,  however,  a  long-continued  affec- 
tion, having  less  severe  symptoms,  less  tenesmus,  the  stools  con- 
taining large  quantities  of  mucus,  very  little  blood,  and  no  pus. 
In  mucous  disease  the  evidences  of  general  malnutrition  are 
greater  and  more  slowly  progressive  than  in  dysentery.  The 
diphtheric  form  is  seldom  seen  in  infants,  and,  indeed,  is  very 
rare,  even  in  older  children.  Its  onset  may  be  either  very  rapid 
or  slow,  but  the  symptoms  are  much  more  severe  than  those  of 
the  acute  catarrhal  variety.  The  pseudomembrane  found  in  the 
stools  greatly  aids  in  the  diagnosis.  Amebic  dysentery  is  a  rare 
disease  in  this  climate.  When  found,  the  stools  will  be  seen  to  have 
a  grayish-yellow  color  and  contain  blood  and  mucus  (Adams). 
Its  diagnostic  points  are  the  recurring  attacks  of  diarrhea  and  the 
presence  of  amebae  in  the  stools. 

Prognosis. — The  average  duration  of  the  acute  attack  of 
catarrhal  ileocolitis  is  from  a  week  to  ten  days,  and  with  proper 
treatment  should  end  favorably.  The  prognosis  varies,  however, 
when  the  disease  is  epidemic,  the  mortality  in  some  epidemics 
being  very  high.  Even  the  acute  variety  may  end  fatally  in  from 
twelve  to  thirty-six  hours.  Favorable  indications  are  bowel 
movements  of  moderate  amount  and  decreasing  frequency,  small 


ILEOCOLITIS.  215 

quantities  of  blood  being  passed,  with  slight  tenesmus  and  not  a 
great  deal  of  weakness  following.  A  good,  strong  heart  action, 
the  absence  of  nervous  depression,  and  no  convulsions  are  all  evi- 
dences of  a  light  attack  of  the  disease. 

Treatment. — The  treatment  of  ileocolitis  may  be  divided  into 
preventive  and  curative.  The  former  may  be  secured  by  a  care- 
ful oversight  of  the  child's  diet  and  hygiene,  the  same  rules  being 
followed  as  have  been  given  in  the  treatment  of  other  forms  of 
intestinal  disease.  These  rules  should  be  carried  out  with 
especial  strictness  and  care  during  the  summer  months,  extra 
precautions  being  taken  when  the  disease  is  epidemic,  remember- 
ing especially  that  no  attack  of  indigestion,  however  slight,  in  a 
child  is  too  small  a  thing  to  warrant  the  attention  of  the  physician. 
Many  a  fatal  attack  of  dysentery  could  be  checked  in  the  in- 
cipient stage  were  intelligent  medical  aid  called  at  this  time. 
When  the  child  has  been  fed  on  artificial  foods  containing  milk 
or  starch,  it  is  best  to  stop  these  for  a  few  hours  and  substitute  a 
diet  of  beef-juice  or  broths.  When  breast  fed,  allow  the  child  to 
nurse  at  rather  more  frequent  intervals  and  to  take  very  small 
quantities  at  each  nursing ;  but  even  in  this  case,  if  the  patient 
has  symptoms  of  a  severe  attack,  it  is  better  to  stop  the  milk 
entirely.  In  older  children  the  diet  is  to  be  restricted  to  the 
lightest  kind  of  proteid  foods.  A  liberal  supply  of  sterilized 
water  or  mineral  waters,  always  given  in  small  quantities  and  fre- 
quently, may  be  allowed.  Bad  cases  with  severe  gastric  compli- 
cations may  require  lavage,  and  when  the  child  is  unable  to 
swallow,  it  may  be  fed  by  a  stomach-tube.  Rectal  alimen- 
tation is  contraindicated  in  this  disease,  and  foods  which  are 
principally  digested  in  the  intestines  should  be  prescribed  with 
great  caution  or  prohibited  entirely.  As  soon  as  the  amount 
of  blood  in  the  stools  lessens,  the  patient,  if  a  young  child, 
may  have  modified  milk.  The  physician  should  personally 
supervise  the  composition  of  the  food  for  each  day,  regulat- 
ing the  quantities  of  the  milk  elements  as  may  best  suit  the 
feeble  digestive  powers  of  the  patient.  Strict  attention  must  be 
paid  to  cleanliness  and  a  good  supply  of  fresh  air.  If  possible, 
remove  the  child  to  the  mountains  or  seashore,  the  latter  fre- 
quently proving  the  better.  In  both,  however,  it  is  hard  for 
the  physician  to  so  carefully  supervise  the  diet  of  the  child,  for 
this  must  receive  the  greatest  care  even  after  the  symptoms  of 
the  acute  attack  have  ceased.  Daily  sponge -baths  should  be 
given  all  through  the  attack.  If  the  patient  is  an  infant,  a  very 
important  point  is  the  disinfection  of  the  diapers  ;  these  should 
be  well  boiled  and  soaked  in  a  solution  of  corrosive  sub- 


2l6  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

limatc,  carbolic  acid,  or  chlorin  preparations  as  soon  as  re- 
moved. 

In  dysentery,  as  in  other  forms  of  intestinal  inflammation,  the 
greatest  benefit  is  always  to  be  derived  from  local  treatment  by 
intestinal  irrigations  ;  here  it  is  of  importance  that  the  irrigation, 
while  it  should  be  copious  enough  to  thoroughly  flush  and 
cleanse  the  bowel,  it  should  be  allowed  sufficient  means  of  ingress 
and  egress.  It  is  better  that  the  bowel  should  not  be  distended 
to  an  extent  sufficient  to  produce  pain  ;  and  it  should  also  be 
remembered  that  the  lining  of  the  large  intestine  is  thinned  by 
ulceration,  so  that  there  is  always  at  least  a  moderate  danger  of 
perforation  when  the  liquid  is  forcibly  injected  or  the  bowel  is 
overdistended  by  too  much  fluid.  Irrigation  can  best  be  accom- 
plished by  a  soft-rubber  two-way  catheter,  or  by  using  two 
ordinary  soft-rubber  catheters  of  about  numbers  12  to  14  of  the 
French  scale.  Through  one  of  these  the  irrigating  fluid  is  to  be 
introduced,  while  the  other  is  for  the  return  flow.  These  should 
be  well  oiled  and  introduced  with  very  great  gentleness  to  a  dis- 
tance of  four  or  five  inches.  A  quart  of  water  may  be  used  in 
each  irrigation  in  a  child  from  two  to  five  years  old.  The  return 
flow  must  be  watched  to  see  that  the  fluid  is  not  retained.  The 
gravity  or  bag  syringe  is  the  only  safe  form  to  use  for  this 
purpose,  and  the  reservoir  should  not  be  over  three  or  four 
feet  from  the  floor.  The  water  used  in  the  irrigation  may  be 
medicated  with  any  one  of  the  numerous  intestinal  antiseptics, 
but  in  many  cases  warm  sterilized  water  made  slightly  alkaline 
by  one  dram  of  sodium  chlorid  to  the  pint  of  water  will  give 
good  results.  Many  authors  claim  to  have  excellent  results 
by  using  irrigations  of  iced  water,  or  by  gradually  lowering 
the  temperature  of  the  water  during  irrigation.  The  number  of 
irrigations  must  depend  on  the  amount  of  diarrhea  present ;  as 
this  lessens,  they  may  be  given  at  increasing  intervals.  When 
the  pain  and  tenesmus  are  increased  greatly  by  the  introduction 
of  the  tube,  the  rectum  may  be  anesthetized  by  cocain  in  the 
strength  of  2  to  4  per  cent.,  the  agent  being  used  alone  or  with 
carbolic  acid  ;  these  maybe  brushed  over  the  mucous  membrane 
or  introduced  in  the  form  of  a  suppository  with  cocoa-butter. 
Some  authors  contend  that  the  same  effect  is  produced  by  a  small 
ice-bag  applied  to  the  anus  or  by  an  ice  suppository. 

Out  of  all  the  large  number  of  drugs,  antiseptic  and  astringent, 
which  have  at  various  times  been  recommended  as  cures  for  this 
disease,  there  is  no  one  upon  which  we  can  absolutely  rely  as  a  spe- 
cific. Complex  prescriptions  should  be  avoided,  and  the  innum- 
erable new  remedies  should  be  tried  with  very  great  caution,  as 


ILEOCOLITIS.  217 

through  their  use  in  many  cases  the  physician  does  more  harm 
than  good.  Of  the  astringent  antiseptics,  the  best  are  probably 
bismuth  and  its  salts,  particularly  the  subgallate  and  subnitrate. 
Ipecacuanha  has,  in  our  hands,  given  moderately  good  results, 
and  calomel  has  probably  given  the  best  results  of  all.  The 
following  prescription  is  recommended  : 

U .     Pulv.  ipecac. , gr.  ss 

Mass,  hydrarg., gr.  iij 

Pulv.  aromatic., gr.  iv 

Sacchar.  alb., gr.  xv. 

Mix  and  make  into  ten  powders. 

SlG. — One  every  two  hours. 

In  the  beginning  of  the  attack  good  results  are  often  obtained 
by  administering  a  dram  of  castor  oil  with  a  few  drops  of  cam- 
phorated tincture  of  opium,  the  latter  to  prevent  griping,  or  a 
single  dose  of  sulphate  of  magnesia  may  prove  beneficial.  The 
mineral  astringents  give  their  best  action  after  the  disease  has 
progressed  for  some  little  time,  and  it  is  then  that  the  bismuth 
salts  and  a  few  of  the  intestinal  antiseptics,  particularly  salol, 
give  their  best  results.  For  the  pain  and  tenesmus  analgesic 
suppositories  of  the  formula  below  are  useful,  one  every  hour  or 
more  : 

Cocain  hydrochlorate, I  grain 

Aqueous  extract  of  ergot,  . 12  grains 

Aristol,      5     " 

Cocoa-butter,  to  make  twelve  suppositories. 

Preparations  of  opium  should  be  used  with  extreme  caution 
in  dysentery  in  children.  When  the  disease  has  progressed  for 
several  days,  the  camphorated  tincture  may  be  used  with  safety, 
and  may  be  combined  in  small  doses  with  any  of  the  before- 
mentioned  prescriptions.  Naphthol,  the  sulphocarbolate  of  zinc, 
and  bichlorid  of  mercury  have  all  been  used  and  have  their  ad- 
vocates. Alcoholic  stimulants  are  especially  indicated  when 
weakness  is  great,  and  hot  fomentations  may  be  applied  over  the 
abdomen.  Enemata  of  small  quantities  of  opium  and  starch 
water — five  or  six  ounces  of  warm  mucilage  of  starch  and  boric 
acid,  with  ten  minims  of  tincture  of  opium,  will  often  be  of  service 
after  the  disease  has  continued  some  days. 

In  amebic  dysentery  Councilman  and  Lafleur  recommend  the 
use  of  solutions  of  quinin,  in  a  strength  of  I  :  5000  to  I  :  1000, 
by  intestinal  irrigation.  Injections  are  given  with  the  patient  in 
a  knee-chest  position. 

The  treatment  of  diphtheric  dysentery  is  practically  the  same 
as  in  other  forms. 


2l8  DISEASES    OF    THE    DIGESTIVE    ORGANS. 


AMYLOID  DEGENERATION  OF  THE  INTESTINES. 

This  form  of  intestinal  disease  is  most  commonly  found  asso- 
ciated with  the  same  changes  in  other  organs,  particularly  the 
liver,  spleen,  and  kidneys,  where  it  usually  appears  as  the  result 
of  prolonged  suppuration.  More  rarely  it  is  associated  with 
syphilis.  The  ileum  is  most  apt  to  be  attacked.  The  disease  is 
rare  in  infants,  but  is  occasionally  seen  in  older  children. 

Pathology. — The  changes  begin  in  the  walls  of  the  capillaries 
and  small  arteries  of  the  intestinal  villi,  but  later  the  submucosa, 
and  even  the  mucous  membrane  of  the  intestine,  may  be  affected. 
The  latter  has  the  characteristic  pale,  semitranslucent  appearance 
which  is  found  in  amyloid  degeneration  elsewhere.  The  same 
chemic  tests  as  are  used  in  the  recognition  of  amyloid  diseases 
of  the  liver  are  of  service  here.  Amyloid  degeneration  of  the 
intestines  has  no  special  symptoms. 

The  treatment  is  entirely  symptomatic. 


MUCOUS  DISEASE. 

Synonyms. — CHRONIC  GASTRO-INTESTINAL  CATARRH  ;  CHRONIC 

FOLLICULAR  INFLAMMATION  OF  THE  INTESTINAL  Mucous 

MEMBRANE  ;  INTESTINAL  DESQUAMATIVE  CATARRH  ; 

CHRONIC  CROUP  OF  THE  INTESTINES,  ETC. 

Under  this  name  is  described  (Eustace  Smith)  a  form  of 
chronic  intestinal  catarrh  characterized  by  the  discharge  from  the 
bowels  of  shreds  or  tubes  of  membrane  composed  principally  of 
mucin.  The  evacuations  of  the  bowels  are  preceded  by  attacks 
of  abdominal  pain  and  are  generally  unaccompanied  by  fever. 
The  disease  usually  occurs  from  the  second  to  the  tenth  year, 
but  is  occasionally  found  in  very  young  infants. 

Causes. — The  cause  of  the  increased  secretion  of  mucus  is 
often  obscure.  It  is  probable  that  it  is  not  primarily  of  bacterial 
origin,  although  it  is  certain  that  the  number  and  variety  of  micro- 
organisms usually  found  in  the  intestines  are  greatly  increased  in 
this  disease,  especially  during  an  acute  attack.  It  seems  probable 
that  a  general  lowering  of  the  tone  or  disorganization  of  the 
nerve  supply  governing  the  functions  of  nutrition  and  assimila- 
tion may  be  a  potent  cause.  Goodhart  believes  the  disease  to  be 
of  nervous  origin,  and  attributes  the  usual  combination  of  vague 
symptoms  to  nervous  instability,  and  says  that  these  children  are 
very  frequently  the  offspring  of  nervous  parents,  are  descendants 
of  families  affected  with  diseases  of  the  nervous  system,  such  as 


MUCOUS    DISEASE.  2IQ 

those  in  which  epilepsy,  hysteria,  insanity,  neuralgia,  and  sudden 
outbursts  of  temper  are  found,  or  families  in  which  gout,  rheu- 
matism, or  kidney  diseases  have  been  transmitted  from  one  gen- 
eration to  another. 

Pathology. — The  mucous  membrane  of  the  intestine  becomes 
thickened,  the  glandular  follicles  in  both  the  small  and  the  large 
intestine,  and  especially  those  of  the  sigmoid  flexure  and  descend- 
ing colon,  become  enlarged  and  ulcerated.  The  character  of  the 
mucus  is  at  first  clear  or  jelly-like  and  imperfectly  membran- 
ous ;  secondly,  it  is  semiopaque  or  flaky,  and,  lastly,  yellowish- 
white,  tough,  and  distinctly  membranous,  adhering  closely  to 
the  intestinal  surface. 

Symptoms. — The  child's  appetite  becomes  capricious,  and,  in 
the  course  of  a  few  days,  fails  almost  entirely.  There  is  pain  or 
flatulence,  or  both,  after  taking  food.  Occasionally  the  child  has 
an  almost  constant  craving  for  food  and  will  eat  large  quantities 
of  it.  No  matter  what  the  condition  of  the  appetite  is,  the  patient 
fails  rapidly  and  progressively,  the  loss  of  bodily  weight  being 
constant.  The  skin  is  pale  or  of  an  unhealthy  sallow  color  ; 
very  frequently  it  is  harsh  and  scaly.  The  urine  is  dark  and 
highly  colored,  of  high  specific  gravity,  and  contains  a  large 
amount  of  urates.  When  no  complications  exist,  neither  albumin 
nor  sugar  can  be  found.  Nervously,  the  child  is  erratic  and 
generally  depressed,  irritable,  or  melancholic.  Infants  affected 
by  the  disease  cry  almost  all  the  time,  with  that  peculiar  whin- 
ing, irritable  cry  so  commonly  found  in  diseases  of  the  digestive 
organs.  They  are  peevish  and  impossible  to  amuse.  Older 
children  are  equally  cross,  or  are  hysteric,  hypochondriacal,  and 
with  bad  memories  or  melancholia.  Insomnia  and  night-terrors, 
with  incontinence  of  urine,  are  almost  constant  symptoms.  Odd, 
irregular  forms  of  skin  affections,  particularly  forms  of  herpes, 
sometimes  appear.  Occasionally  boils  and  carbuncles  are  seen. 
Ulcerative  stomatitis  is  very  often  present,  and  in  older  children 
chorea,  defects  of  vision,  muscular  tremors,  disorders  of  cutane- 
ous sensation,  and  in  fact  all  the  chain  of  symptoms  known  as 
hysteroid,  may  be  exhibited.  The  tongue  is  pale  and  anemic 
looking,  with  deep  fissures  in  its  center.  A  shiny,  gum-like 
coating  generally  covers  it.  Occasionally,  however,  it  is  clear, 
stripped  of  epithelium,  and  glazed.  Aphthous  ulcers  of  the 
mouth  and  tonsils  are  common.  The  attack  is  often  preceded 
by  symptoms  of  general  indigestion,  with  a  sense  of  dull  pain  or 
uneasiness  in  the  region  of  the  umbilicus  or  over  the  head  of  the 
colon.  These  symptoms  may  continue  or  be  increased  during 
an  attack.  The  abdomen  is  somewhat  distended  and  tender. 


22O  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

The  attack  may  be  preceded  by  some  chilliness,  during  which 
the  child's  finger-nails  turn  a  little  blue.  There  is  seldom,  if  ever, 
any  change  or  rise  of  temperature.  Frequently  the  temperature 
is  subnormal.  Vomiting  is  infrequent.  In  one  case  we  have 
seen  the  attack  preceded  by  symptoms  resembling  catarrh  in  the 
upper  air-passages.  The  number  of  bowel  movements  varies 
greatly.  Occasionally  the  child  will  be  constipated,  even  during 
the  attack,  as  in  a  case  in  the  practice  of  one  of  the  authors. 
Mildly  alkaline  enemata  will  bring  away  enormous  quantities  of 
thin  mucus.  In  other  cases  the  stools  are  frequently  preceded 
and  accompanied  by  pain  and  flatulence.  The  breath  is  gener- 
ally offensive,  the  odor  being  described  by  some  as  being  sweet, 
heavy,  aromatic,  or  resembling  that  of  chloroform.  The  tonsils 
are  nearly  always  enlarged  and  prone  to  inflammations.  The 
disease  frequently  occurs  in  paroxysms,  and  between  these 
attacks  the  child's  condition  may  improve  ;  the  bowels  are  more 
regular,  may,  in  fact,  be  even  constipated,  and  the  stools  contain 
little  or  no  mucus.  During  the  attack  the  stools  are  soft,  light 
brown  or  pale  in  color,  and  putty-like  in  consistence ;  they 
always  contain  large  quantities  of  mucus.  Small  collections  of 
worms  are  frequently  found  in  them.  A  microscopic  examina- 
tion of  the  stools  will  show  that  they  are  made  up  of  opaque, 
solid,  white  masses,  molded  or  flattened,  and  small,  flocculent 
pieces  of  semitransparent  membrane.  The  pieces  of  membrane 
will,  upon  examination  with  a  low-power  objective,  be  seen  to  be 
composed  of  mucous  and  epithelial  cells  which  have  undergone 
fatty  degeneration.  Certain  vasomotor  symptoms,  such  as  a  cir- 
cumscribed flush  upon  the  cheeks,  appear  especially  in  the  after- 
noon, and  around  the  mouth  there  is  generally  a  dusky  pallor. 
Children  thus  affected  frequently  pick  at  the  nose,  showing  altera- 
tion or  irritation  of  reflex  origin  in  the  mucous  membrane  of  the 
nose — a  group  of  symptoms  which  has  been  long  ascribed  to  the 
presence  of  worms. 

Diagnosis. — From  the  color  and  shape  of  the  pieces  of  mem- 
brane passed  the  disease  may  be  confounded  with  tapeworm,  but 
the  characteristic  symptoms  and  the  large  amount  of  mucus  ex- 
creted should  serve  to  differentiate.  The  diagnosis  can  be  con- 
firmed by  the  microscopic  examination  of  the  discharges.  It 
should  not  be  forgotten  that  in  older  children  it  is  possible  for 
tapeworm  to  be  coexistent  with  this  disease.  The  disease  to 
which  mucous  enteritis  bears  the  closest  resemblance  is  general 
tuberculosis  or  pulmonary  tuberculosis  with  intestinal  compli- 
cations. In  tuberculosis  we  have  the  regularly  recurring  fever, 
while  in  mucous  disease  there  is  no  rise  of  temperature,  the 


MUCOUS    DISEASE.  221 

latter  being  often  subnormal,  except  occasionally  during  the 
attack.  It  would  be  well,  however,  in  all  cases  presenting  the 
symptoms  of  mucous  disease  to  examine  the  lungs. 

Prognosis. — With  a  carefully  regulated  diet  and  good  general 
treatment  the  prognosis  is  favorable,  although  the  disease  gener- 
ally runs  a  very  tedious  course.  Many  cases  continue  for  years, 
with  occasional  recurrences.  The  fundamental  lesion  is  a  neuro- 
sis, a  lowered  tone  of  the  system  which  may  be  beyond  repair. 

Treatment. — The  most  important  part  of  the  treatment  of 
mucous  enteritis  undoubtedly  consists  in  the  careful  regulation 
of  the  daily  life  of  the  child  and  a  strict  supervision  of  its  diet. 
It  is  impossible  to  lay  down  any  fixed  rule  that  will  fit  every 
case.  We  must  study  the  character  of  the  individual  patient 
and  place  the  child,  as  far  as  possible,  amid  those  surroundings 
which  are  most  soothing  to  its  excitable,  nervous  state.  It  is  of 
the  greatest  importance  that  such  children  be  not  forced  in  their 
education,  nor  kept  at  school  for  too  long  hours.  They  should 
be  allowed  to  live  in  the  open  air  as  much  as  possible,  and  in  a 
climate  where  the  temperature  is  nearly  even  throughout  the 
year.  In  the  Eastern  States  it  has  been  our  experience  that  they 
do  remarkably  well  at  the  seashore ;  however,  we  find  cases 
that  do  much  better  in  mountainous  regions.  Almost  any  con- 
dition where  they  can  be  allowed  to  live  in  the  open  air,  with 
plenty  of  gentle  outdoor  exercise,  particularly  if  these  exercises 
are  in  the  form  of  the  ordinary  plays  and  games  of  childhood, 
will  do  the  patient  good.  Young  infants  should  be  placed  in 
their  coaches  and  allowed  to  remain  in  the  open  air  for  as  much 
of  the  day  as  possible.  At  night  they  should  sleep  on  a 
moderately  firm  mattress,  in  a  well-ventilated  room,  and  they 
should  sleep  alone.  It  is  of  importance  that  the  child  receive  a 
daily  bath  ;  the  water  of  this  bath  should  be  tepid  or  slightly 
cool,  and  its  efficiency  is  sometimes  increased  by  dissolving  in  it 
a  lump  of  rock-salt  as  large  as  an  apple  ;  otherwise  the  child 
should  be  afterward  sponged  with  alcohol  and  rubbed  thor- 
oughly with  a  moderately  coarse  towel  until  the  skin  is  pink. 
When  there  is  considerable  emaciation  and  nutrition  is  bad,  the 
entire  body  may  be  rubbed  with  either  olive  or  cod-liver  oil. 
The  ordinary  cotton-seed  oil — the  so-called  olive  oil  of  the 
market — will  do  equally  well.  The  efficiency  of  oil  inunctions 
is  often  increased  by  the  addition  of  alcohol,  in  the  proportion 
of  about  one  part  of  alcohol  to  three  parts  of  oil.  Unless  there 
is  some  special  indication  for  it,  it  is  best  not  to  administer 
cod-liver  oil  by  the  mouth,  as  fats  are  but  very  poorly  digested 
by  these  children,  and  there  is  danger  of  impairing  what  little 


222  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

digestive  action  they  have  left.     When  fats  can  be  assimilated, 
one  of  the  best  formulas  to  use  is  as  follows  : 

Olive  oil, 2  ounces 

Glycerin, I  ounce 

The  yolk  of  one  egg 

Some  aromatic  substance,  as  an  elixir  of  pancreatin. 

The  foregoing,  thoroughly  shaken,  makes  a  good  emulsion,  and 
to  it  may  be  added  one-half  minim  of  creasote  to  each  dram  of 
the  mixture.  Of  this,  one  teaspoonful  may  be  given  three  times 
a  day  after  feeding. 

The  diet  is  a  matter  of  the  very  greatest  importance,  and  here 
we  must  again  consider  the  needs  of  the  individual  case.  It  is 
almost  impossible  to  lay  down  any  general  regulations  for  the 
feeding  of  these  cases.  As  a  rule,  starchy  or  farinaceous  foods 
should  be  excluded,  and  articles  of  diet  rich  in  fat  must  be 
either  prohibited  or  given  with  the  utmost  caution.  Generally 
speaking  a  diet-list  similar  to  that  used  in  the  treatment  of 
subacute  gastro-intestinal  catarrh  is  of  use  here.  Milk  should 
be  given  with  caution,  and  should  always  be  guarded  by  the 
addition  of  bicarbonate  of  soda,  lime-water,  or  even  common 
table  salt.  Beef-juice,  consomme,  veal  broth,  or  chicken  soup, 
either  plain  or  with  the  addition  of  a  small  quantity  of  rice  or 
barley,  are  useful.  In  young  children  milk  so  modified  as  to 
contain  a  small  quantity  of  fat  and  a  rather  high  percentage 
of  proteids  answers  very  well.  During  an  attack  it  is  often 
necessary  to  exclude  milk  altogether.  Moderate  amounts  of 
alcohol  may  be  given  with  advantage,  particularly  in  older 
children  ;  in  these  cases  one-half  ounce  to  one  ounce  of  any 
good  dry  wine,  diluted  in  two  or  three  parts  of  water,  may  be 
given  with  advantage  once  or  twice  a  day  at  meals.  In  the 
medicinal  treatment  we  have  no  remedy  or  combination  of 
remedies  that  can  be  claimed  as  specific.  Our  object  in  the 
administration  of  drugs  should  be  to  keep  the  intestines  as  free 
as  possible  from  infective  bacteria  and  remove  the  adherent  mucus. 
The  agents  which  have  had  the  greatest  amount  of  success  for  this 
purpose  are  probably  salol,  the  subnitrate,  subgallate,  or  sal  icy- 
late  of  bismuth,  naphthol,  and  naphthalene.  Beta-naphthol  bis- 
muth has  also  been  greatly  praised  for  this  purpose.  A  few  of 
the  formulas  recommended  by  Dujardin-Beaumetz,  Droyxhe, 
and  others  are  given  below  : 

R.    Salol, 

Bismuthi  salicylat., 

Sodii  bicar., aa    gr.  cL 

M.     Divide  into  capsules  No.  xxx. 
SIG. — One  capsule  before  breakfast  and  dinner. 


MUCOUS    DISEASE.  223 

R.     Resorcin., gr.  ii-vij 

Syrup,  aurantii, f 5j 

Aqua  citronelle,       q.s.  adf^iv. 

SlG. — Three  teaspoonfuls  every  three  hours. 

As  in  many  cases  the  bowel  movements  are  highly  acid,  espe- 
cially when  the  child  has  been  for  a  long  time  on  a  milk  diet,  the 
following  may  be  used  : 

1£ .     Hyclrarg.  chlorid.  mite, gr.  iij 

Sodii  phosph., 

Sodii  bicarb., aa    gij. 

M.     Divide  in  chart  No.  xxiv. 
Sic. — One  powder  every  three  hours. 

R.     Creolin, gtt.  i-ij 

Syrup-,     •    • f£j 

Aqua  menthce  piperit., ^5^}- 

M.     SIG. — Teaspoonful  every  two  or  three  hours. 

Beta-naphthol  bismuth  may  be  given  in  doses  of  from  two  to 
five  grains,  according  to  the  age  of  the  child,  and  repeated  three 
or  four  times  a  day.  The  action  of  this  agent  has  been  highly 
lauded  by  many  authorities.  In  the  authors'  hands  it  has  given 
moderately  good  results.  We  would  not  consider  it  a  better 
intestinal  antiseptic  or  superior  in  any  way  to  the  other  bismuth 
salts  or  salol,  or  a  combination  of  these  two. 

When  constipation  exists,  mild  saline  laxatives  or  aperient 
waters  are  useful.  This  class  of  remedies  not  only  relieves  the 
constipation,  but  aids  in  clearing  the  intestine  of  a  considerable 
amount  of  mucus.  Probably  the  most  satisfactory  method  of 
treatment  consists  in  irrigation  of  the  intestines  once  or  twice 
a  day. 

Gastric  lavage  has  been  highly  recommended  by  many  authori- 
ties. In  order  to  wash  out  the  stomach,  a  soft  Nelaton's  catheter 
of  number  nine  or  ten  size  is  attached  by  a  short  glass  tube  to  a 
rubber  tube,  which  in  its  turn  is  attached  to  a  glass  funnel.  The 
catheter  should  be  gently  passed  into  the  stomach  of  the  child 
and  the  irrigating  solution  poured  into  the  funnel  from  a  pitcher ; 
about  two  ounces  may  be  introduced  at  a  time.  After  each 
introduction  of  the  fluid  the  funnel  should  be  lowered  and  the 
contents  of  the  stomach  allowed  to  flow  out. 

About  two  liters  of  water,  to  which  is  added  a  teaspoonful  of 
bicarbonate  of  soda  or  a  few  drops  of  a  6  per  cent,  solution  of 
sodium  benzoate,  should  be  used  during  the  irrigation.  More 
liquid  should  be  introduced,  and  allowed  to  flow  back  again 
until  it  comes  out  clear.  It  must  not  be  forgotten  that  occa- 
sionally considerable  shock,  and  even  convulsions,  may  follow 
irrigation  of  the  stomach,  yet  this  method  of  treatment  is  cer- 


224  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

tainly  followed  by  the  very  best  results.  Massage  of  the 
abdomen  is  of  undoubted  use  in  these  cases.  Cutaneous  elec- 
trization of  the  abdomen  has  been  recommended  by  von  Ziemssen 
and  others.  This  treatment  should  be  administered  about  half 
an  hour  before  meals  ;  large  electrodes  are  to  be  used,  one  being 
placed  upon  the  back  and  another  upon  the  abdomen.  General 
faradism  has  also  been  recommended.  In  cases  where  anemia 
is  a  prominent  symptom,  tonics,  such  as  nux  vomica,  iron,  or 
quinin,  are  indicated.  Hydrochloric  or  nitrohydrochloric  acid 
administered  immediately  after  meals  is  of  the  greatest  benefit 
in  many  cases.  Enuresis  and  night-terrors  can  frequently  be 
controlled  by  diet  and  by  not  allowing  the  child  to  eat  too  near 
its  bedtime.  Arsenic,  belladonna,  sulphonal,  and  many  other 
remedies  have  been  used  to  control  this  condition ;  the  last 
remedy,  given  in  capsules  of  two  or  three  grains  each,  and 
repeated  once,  has  frequently  given  excellent  results. 

CHRONIC  CONSTIPATION. 

By  chronic  constipation  we  understand  a  condition  in  which 
the  contents  of  the  bowels  are  not  evacuated  with  ,what,  in  a 
given  case,  would  be  normal  regularity  and  in  less  than  normal 
amounts  ;  the  consistency  of  the  evacuations  is  also  increased,  so 
that  the  effort  of  emptying  the  bowel  is  attended  with  consider- 
able pain  and  muscular  effort.  We  must  understand  by  consti- 
pation that  the  number  of  evacuations  is  less  than  would  be  the 
normal  in  a  given  individual  at  a  given  age  ;  thus,  during  the  first 
year  of  life  an  infant  may  have  from  two  to  four,  or  even  five, 
discharges  without  being  considered  to  have  had  more  than  the 
normal  number.  In  the  second  year  of  life  the  number  of 
evacuations  is  generally  about  two  or  three  a  day,  and  from  that 
time  on  they  will  diminish  until  the  individual  has  one  normal 
stool  a  day.  Constipation  may  be  described  under  two  forms  : 
the  atonic  and  the  spasmodic.  The  atonic  form  is  generally  due 
to  a  lack  of  the  proper  peristaltic  motion  of  the  intestines.  In 
the  spasmodic  form  the  fecal  movements  are  usually  increased 
in  size,  and  are  much  harder  than  normal ;  this  will  frequently 
produce  an  irritable  condition  of  the  rectum,  so  that  the  pain  of 
a  bowel  movement  is  so  great  that  the  child  will  not  willingly 
endeavor  to  have  a  fecal  evacuation. 

Causes. — The  causes  of  constipation  are  varied ;  thus,  the 
conformation  of  the  large  intestines  in  the  child  may  in  itself  be 
a  cause,  as  during  this  period  of  life  the  ascending  and  the  trans- 
verse colon  are  shorter,  and  the  descending  colon  is  longer,  than 


CHRONIC    CONSTIPATION.  225 

in  the  adult.  In  the  child  there  are  a  greater  number  of  curves 
in  the  intestinal  canal ;  the  culdesac  of  the  sigmoid  flexure  is  deeper, 
this  being  especially  noticeable  just  above  the  rectum.  The  small 
space  in  the  interior  of  the  child's  pelvis  into  which  many  abdom- 
inal organs  are  crowded  may  tend  to  produce  constipation.  The 
imperfectly  developed  condition  of  the  intestines  themselves  and 
their  lack  of  general  muscular  tone  are  both  factors  in  the  pro- 
duction of  flexions  or  twists,  especially  in  the  lower  bowel. 
Food,  also,  is  a  very  important  causative  factor,  especially  when 
this  is  in  a  state  of  partial  fermentation.  Milk  itself,  usually  the 
proper  food  for  the  child,  will,  when  in  a  condition  unadapted  to 
the  digestive  organs,  produce  constipation,  and  a  continued  diet 
of  cereals  is  apt  to  give  the  same  results.  A  deficient  excretion 
of  bile  may  also  be  a  cause.  Various  malformations,  tumors, 
etc.,  may  act  as  etiologic  factors.  Constipation  usually  follows 
the  administration  of  certain  laxative  drugs  after  the  period  of 
their  action  has  ceased.  In  the  majority  of  mild  cases  no  patho- 
logic changes  are  noticed.  When  the  condition  has  been  intense 
and  has  lasted  for  considerable  time,  there  is  frequently  some 
irritation  of  the  lower  bowel,  accompanied  by  a  catarrhal  condi- 
tion, giving  rise  to  symptoms  that  may  for  a  time  simulate 
diarrhea.  In  bad  cases  an  actual  ulceration  of  the  bowel  may 
result,  although  this  is  rare. 

Symptoms. — The  symptoms  are,  for  a  time,  more  or  less 
obscure.  However,  there  are  generally  present  some  headache, 
restlessness,  occasionally  a  slight  rise  of  temperature,  distention 
and  tenderness  of  the  abdomen,  and  upon  examination  the  trans- 
verse colon  can  generally  be  outlined  by  palpation  and  percus- 
sion. In  very  severe  cases  there  may  be  dyspnea,  and  even 
convulsions  of  eclamptic  type.  Palpitation  of  the  heart  and  ver- 
tigo are  often  present.  If  the  condition  continues  for  some  time, 
the  child  loses  its  appetite,  becomes  restless  and  fretful,  com- 
plaining of  almost  constant  abdominal  pain,  generally  expressed 
by  crying  and  drawing  up  of  the  legs. 

Treatment. — The  treatment  should  consist  in  a  speedy  and 
thorough  evacuation  of  the  intestinal  contents.  For  this  pur- 
pose the  child  should  be  given  a  full  dose  of  some  brisk  laxative, 
such  as  calomel,  and  the  emptying  of  the  lower  bowel  facilitated 
by  an  enema.  This  may  be  composed  of  plain  soapsuds  or  of 
glycerin  or  salt  and  water ;  suppositories,  too,  fill  an  important 
place  in  the  treatment  of  this  condition.  These  may  be  made  of 
plain  Castile  soap,  of  glycerin,  or  of  gluten.  Injections  of  plain 
cold  water  have  been  recommended  by  some.  One  of  the  most 
important  agents  in  the  therapeutics  of  this  condition  is  abdom- 


226  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

inal  massage.  This  should  be  administered  by  some  one  who  un- 
derstands how  to  apply  it  correctly  ;  a  mother  or  nurse  can  readily 
be  taught  to  do  so.  The  movements  should  follow  the  course 
of  the  large  intestines,  and  thence  extend  over  the  whole  of  the 
abdomen.  The  application  may  be  made  for  a  period  of  not 
over  three  minutes  at  the  beginning,  the  length  of  the  treatment 
being  gradually  increased  from  day  to  day.  Both  galvanism  and 
faradism  of  the  abdomen  have  been  recommended,  but  both  must 
always  hold  a  place  secondary  in  importance  to  massage.  The 
question  of  food  is  an  important  one.  This  should  be  regulated 
according  to  the  needs  of  the  individual  patient.  When  the  child 
has  been  fed  on  a  diet  of  cereals  for  a  long  time,  a  change  to  a 
diet  at  least  partially  composed  of  animal  broths  may  give  bene- 
ficial results;  or,  on  the  other  hand,  not  infrequently  a  slight 
increase  in  the  quantity  of  fat  or  sugar  in  the  food  will  result 
favorably.  In  older  children  fresh  fruits,  such  as  oranges,  grape- 
fruit, etc.,  are  highly  beneficial ;  stewed  fruits  also,  particularly 
stewed  prunes,  stewed  peaches,  or  apricots,  are  of  service.  In 
nursing  children  the  condition  may  sometimes  be  relieved  by  the 
administration  of  laxatives  to  the  mother,  particularly  such  agents 
as  sulphate  of  magnesia  or  castor  oil  ;  also  by  increasing  the 
amount  of  laxative  foods  in  the  mother's  diet.  Many  drugs 
have  been  recommended  for  the  cure  of  constipation,  and  in  the 
treatment  of  the  condition  by  this  means  great  care  must  be 
exercised  to  prevent  the  intestines  becoming  so  habituated  to 
their  use  that  evacuations  can  be  had  only  by  their  aid.  If  pos- 
sible, the  aim  of  the  physician  should  be  to  correct  the  condition 
as  much  as  possible  by  diet  and  general  regimen,  so  that  the 
continued  use  of  drugs  shall  not  be  necessary.  Calomel,  given 
in  doses  of  from  -^  to  -^  of  a  grain  several  times  a  day,  is  of 
great  use,  but  should  not  be  continued  very  long,  partly  because 
of  the  danger  of  producing  constitutional  effects  of  mercury. 
Phosphate  of  soda  is  also  a  remedy  of  considerable  value,  espe- 
cially as  it  is  almost  tasteless  and  may  be  given  in  milk  or  broth. 
It  may  be  administered  in  doses  of  from  two  to  five  grains,  and 
repeated.  Compound  licorice  powder  has  also  been  highly 
recommended,  and  may  be  given  either  alone  or  combined  with 
calomel.  Its  taste  is  not  unpleasant,  but  in  some  cases  it  occa- 
sionally excites  severe  griping.  The  carbonate  and  sulphate  of 
magnesium  are  both  very  useful  agents  ;  the  former  has  compar- 
atively little  taste,  and  may  be  given  in  milk.  The  taste  of  the 
sulphate  is  rather  nauseating,  but  it  may  frequently  be  given  in 
hot  water  or  in  combination  with  tartaric  acid  and  tincture  of 
cardamom,  in  both  of  which  its  taste  is  considerably  disguised. 


INTESTINAL    COLIC.  22/ 

The  fluid  extract  of  cascara  sagrada,  in  doses  of  from  one  to 
five  drops,  is  a  remedy  of  considerable  usefulness,  but  we  have 
frequently  found  that  unless  its  taste  is  disguised,  it  produces 
severe  nausea.  Some  of  the  cascara  cordials  or  other  prepara- 
tions of  the  drug  now  on  the  market  may  be  found  to  obviate 
this  difficulty.  Senna  is  a  favorite  remedy,  valuable  to  use  for  a 
change.  The  tincture  of  nux  vomica,  in  doses  of  from  one  to 
five  drops,  sometimes  aids  in  relieving  the  condition,  and  Fowler's 
solution  and  other  forms  of  arsenic  have  proved  of  very  consider- 
able value  in  the  authors'  hands.  When  flatus  is  a  prominent 
symptom,  such  agents  as  asafetida  or  turpentine  are  of  use. 

INTESTINAL  COLIC. 

The  term  intestinal  colic  is  usually  applied  to  attacks  of  severe 
griping  pain,  paroxysmal  in  character,  occurring  in  the  intestines, 
and  unaccompanied  by  inflammation.  It  is  to  be  distinguished 
from  the  colic  of  appendicitis,  intussusception,  gall-stones,  stran- 
gulated hernia,  and  lead  or  arsenical  poisoning. 

Causes. — Intestinal  colic  is  really  a  symptom  and  not  a  dis- 
ease. It  is  most  frequent  in  the  first  year  of  life,  and  is  probably 
the  most  common  cause  of  pain  during  this  period.  As  seen  in 
infants  and  young  children  it  is  usually  due  to  flatulence  pro- 
duced by  a  mass  of  undigested  food,  chiefly  milk.  In  infants 
up  to  six  months  of  age  its  most  frequent  cause  is  a  milk  too  rich 
in  proteid  or  one  in  which  the  casein  is  in  large  masses  or  so 
tough  that  the  digestive  secretions  can  not  decompose  it.  A  milk 
overrich  in  fat,  and  much  more  rarely  sugar,  may  cause  colic.  The 
farinaceous  foods  long  continued  in  young  infants  very  frequently 
produce  intestinal  distress.  It  is  considerably  more  frequent  in 
bottle-fed  babies  than  in  those  fed  from  the  breast,  although  it  is 
seen  when  the  mother's  milk  has  become  deteriorated  by  continued 
bad  food,  excitement  or  worry,  taking  cold,  or  disease,  or  when  it 
is  too  rich  in  proteids.  Colic  is  frequently  seen  when  the  maternal 
milk-supply  is  limited  in  quantity  or  when  the  colostrum  milk  has 
lasted  beyond  the  usual  period,  and  may  continue  while  the 
mother  is  in  bed.  A  very  common  cause  is  frequent  and  irregular 
feeding,  whether  by  breast  or  bottle.  Pregnancy  or  menstruation 
in  the  mother  may  cause  her  milk  to  give  the  child  colic.  On  the 
part  of  the  infant,  a  naturally  enfeebled  digestive  tract  or  general 
nervous  system  is  a  predisposing  cause,  as  is  also  dentition. 

In  older  children  colic  is  frequently  caused  by  errors  in  diet, 
fruit-seeds,  foreign  bodies,  intestinal  parasites,  and  rarely  plumb- 
ism.  It  not  infrequently  follows  wetting  the  feet  or  exposure 


228  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

to  cold  and  damp.  As  has  been  before  stated,  colic  is  a  symp- 
tom of  appendicitis,  gall-stones,  strangulated  hernia,  and  other 
forms  of  intestinal  inflammation,  and  these  must  always  be  borne 
in  mind  in  studying  a  case. 

Intestinal  colic  is  usually  associated  with  flatulence,  the  latter 
being  caused  by  gas  produced  by  decomposing  food  or  secre- 
tions distending  the  intestines  and  which  can  not  be  expelled, 
but  there  is  in  many  cases  associated  with  this  a  spasm  of  the 
muscular  coats  of  the  intestines  which  is  chiefly  reflex.  This 
latter  is  the  chief  cause  of  the  pain.  In  some  cases  there  is  no 
distention  of  the  intestines,  but  only  reflex  spasm  of  their  mus- 
cular walls  ;  these  latter  cases  are  mostly  the  result  of  taking 
cold  or  getting  the  feet  wet. 

Symptoms  and  Diagnosis. — The  symptoms  of  intestinal 
colic  are  so  well  known  as  to  make  a  lengthy  description  unnec- 
essary. When  the  attack  is  sudden,  the  child's  features,  which 
have  been  placid  a  moment  before,  become  contracted,  the  face 
blanches,  and  in  bad  cases  the  fontanel  always  becomes  de- 
pressed. The  lower  extremities  are  drawn  upon  the  abdomen,  the 
arms  are  flexed,  and  frequently  the  thumbs  are  also  flexed  and 
adducted.  In  male  children  there  is  contraction  of  the  scrotum. 
The  cry  is  loud  and  paroxysmal,  and  is  expressive  of  sharp 
acute  pain.  The  abdomen  will  be  found  hard,  tense,  and  some- 
what distended.  The  attack  may  be  followed  by  expulsion  of 
gas,  and  when  this  occurs,  the  symptoms  quickly  subside  and 
the  child  falls  asleep,  probably  to  be  awakened  in  a  short  time 
by  another  attack.  The  intervals  between  the  paroxysms  may 
be  considerable,  or  the  attacks  follow  one  another  in  rapid  suc- 
cession or  be  almost  continuous.  The  symptoms  may  be  slight 
in  degree  or  severe  enough  to  cause  severe  prostration,  the 
child  being  covered  with  perspiration.  During  the  attack  the 
pulse  is  somewhat  accelerated,  and  the  temperature  in  severe 
cases  may  be  a  little  raised.  Not  infrequently  the  symptoms 
subside  after  taking  food,  particularly  if  it  is  warm.  In  many 
infants  who  are  habitually  badly  fed,  the  colic  is  almost  constant, 
and  in  these  it  is  often  hard  to  distinguish  between  the  cry  of 
hunger  and  that  of  colic ;  in  both  cases  food  is  taken  eagerly 
and  is  generally  followed  by  temporary  relief.  The  cry  of  colic, 
however,  is  more  violent  and  paroxysmal  than  that  of  hunger, 
and  as  the  pain  quickly  returns  after  taking  food,  the  child  will 
again  cry  more  violently  than  before.  In  colic  there  are  also  the 
other  symptoms  expressive  of  pain.  The  cry  of  hunger  is  more 
continuous  and  not  so  shrill,  and  feeding  is  quickly  followed  by 
continuous  relief,  the  child  falling  asleep.  There  are  no  symp- 


INTESTINAL    COLIC.  22Q 

toms  of  general  pain.  The  cry  of  colic  in  infants  several  weeks 
old  must  also  be  distinguished  from  the  cry  of  habit.  The 
abdominal  pain  of  appendicitis,  intussusception,  or  hernia  must 
be  distinguished  by  the  diagnostic  symptoms  of  each  condition 
(see  articles  on  these  subjects).  An  accompanying  gastric  colic 
is  sometimes  seen. 

Treatment. — The  treatment  of  an  attack  of  simple  colic 
consists  in  helping  the  intestines  to  unload  themselves  of  the  gas 
and  decomposing  material  causing  it,  and  to  relieve  the  pain. 
For  the  first  two  there  is  nothing  better  than  an  enema  of  a  half 
pint  of  luke-warm  water,  or,  if  this  fails,  Holt  advises  a  second 
irrigation  of  cold  water  in  which  a  teaspoonful  of  glycerin  is 
dissolved.  The  enema  may  be  made -more  efficacious  by  the 
addition  of  a  few  drops  of  spirits  of  turpentine  or  one  fluidram 
of  milk  of  asafetida.  Dry  heat  may  be  applied  externally  by 
means  of  cloths  or  a  hot  sand,  salt,  or  water-bag.  The 
child's  feet  should  be  kept  warm  by  a  hot-water  bottle  or  bag. 
There  are  a  few  drugs  which,  administered  internally,  may  do 
some  good.  Frequently  a  full  dose  of  castor  oil  will  relieve  in 
a  short  time.  Calomel  in  small  doses  repeated  will  often  do 
good,  or  pepsin,  one  grain,  with  bicarbonate  of  soda,  two  grains, 
given  before  each  nursing  will  sometimes  give  relief.  Probably 
the  quickest  effects  are  to  be  obtained  from  Hoffmann's  anodyne 
or  paregoric,  given  in  doses  of  from  five  to  ten  drops.  The  use 
of  preparations  of  opium,  however,  is  not  advised,  as  they  do 
more  harm  than  good. 

Louis  Starr  and  Hare  recommend  the  following  : 

R .     Chloral  hydrate, gr.'  xvj 

Potass,  bromid. , gr.   xxxij 

Aq.  menth.  piperit., f§ij- 

M.     SIG. — A  teaspoonful  in  a  little  warm  water  every  four  hours  for  a  child 
six  months  old. 

Asafetida,  peppermint,  soda-mint,  the  bromids,  and  arsenic 
are  among  the  remedies  most  commonly  employed.  Between 
the  attacks  the  diet  should  be  regulated,  and  when  this  is 
properly  done,  the  colic  usually  disappears  of  itself.  This  atten- 
tion to  the  diet  must  be  directed  toward  the  composition  of  the 
food.  When  the  proteids  are  high  in  the  breast  milk,  one  may 
tentatively  give  warm  or  tepid  water  before  each  nursing ;  while 
at  the  same  time  he  adopts  the  methods  Rotch  has  suggested,  of 
cutting  down  these  constituents  of  the  mother's  milk  by  diet 
and  exercise.  When  the  infant  is  fed  artificially,  the  proteids 
should  be  lessened  in  the  milk  mixture  given  until  a  formula  is 
prescribed  which  can  be  digested  without  pain.  In  the  weak 


230  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

baby  or  in  one  whose  digestive  functions  are  feeble  the  use  of 
the  hot-water  bag  in  the  crib  serves  to  avert  many  an  attack 
of  nocturnal  pain. 


INTESTINAL  OBSTRUCTION. 

Under  this  title  will  be  described  together  those  forms  of 
stricture  of  the  intestinal  canal,  either  of  sudden  or  gradual 
onset,  which  are  most  commonly  found  in  children.  Among 
these  we  may  include  :  (i)  Strictures  arising  from  organized 
plastic  bands  or  adhesions,  the  result  of  abdominal  inflammation 
by  tumors  or  ulcerations  ;  (2)  from  strangulations  due  to  various 
forms  of  hernia  ;  (3)  from  intussusception  or  invagination  of  the 
bowel;  (4)  volvulus,  or  twisting  of  the  bowel  upon  itself;  (5) 
mechanical  obstructions  caused  by  masses  of  feces  or  foreign 
bodies.  The  last  has  been  already  dwelt  upon  at  some  length 
in  the  article  on  Chronic  Constipation.  In  children  the  most 
common  form  of  obstruction  is  that  known  as  intussusception 
or  invagination  of  the  bowel.  Stricture  resulting  from  bands  of 
organized  lymph,  produced  through  a  previous  attack  of  periton- 
itis, is  occasionally  found.  In  the  majority  of  cases  the*  invagina- 
tion is  direct  and  consists  in  a  slipping  of  one  segment  of  the 
bowel  within  the  other  (like  a  glove-finger  inverted  on  itself), 
the  invaginated  part  being  in  nearly  every  case  the  portion  which 
is  furthest  away  from  the  anus. 

Definitions. — In  a  certain  number  of  cases  the  order  of  the 
invagination  is  reversed,  the  lower  segment  becoming  invaginated 
into  the  upper.  This  is  known  as  retrograde  intussusception. 
The  original  form,  which  has  been  described,  is  known  as  direct 
intussusception.  Intussusception  involves  three  layers  of  bowel, 
each  layer  consisting  of  all  the  intestinal  coats.  The  outer  layer 
is  known  as  the  intussuscipiens,  sheath,  or  receiving  layer,  while 
the  internal  is  known  as  the  entering  layer,  which,  together  with 
the  middle  or  returning  layer,  constitutes  the  invaginated  part  or 
intussusceptum.  The  junction  of  the  middle  and  inner  layer  is 
known  as  the  apex.  Intussusception  may  be  double  or  even  triple. 
In  the  former  case  five  layers  of  intestines  are  involved,  while  in 
the  latter  seven  layers  have  been  found.  While  invagination  of 
the  bowel  may  occur  in  almost  any  portion,  it  is  stated  that  one- 
half  of  all  cases  occur  at  the  junction  of  the  small  and  large  in- 
testines. When  in  this  position  the  ileum  becomes  invaginated  into 
the  colon,  the  condition  is  known  as  ileocolic  intussusception. 
In  less  than  one-third  of  the  whole  number  of  cases  invagination 
takes  place  only  in  the  small  intestine.  This  is  described  as  ileal 


INTESTINAL    OBSTRUCTION. 

or  jejunal  intussusception.  In  a  small  number  of  cases  the  in- 
vagination  may  occur  only  in  the  large  intestine.  This  is  known 
as  colic  intussusception.  In  most  cases  invagination  begins  in 
the  right  side  of  the  abdomen,  but  in  all  the  varieties  except  the 
first  the  position  of  the  neck  continually  changes,  owing  to  the 
following  reason  :  As  the  entering  layer,  or  intussusceptum, 
passes  into  the  sheath,  it  carries  with  it  a  certain  amount  of 
mesentery,  causing  a  considerable  degree  of  traction,  which  pro- 
duces a  curving  or  bending  of  the  intussusceptum  toward  the 
mesenteric  side  of  the  receiving  portion.  In  the  most  common 
variety,  the  ileocecal,  the  invagination  begins  on  the  right  side 
of  the  abdomen,  but  as  the  increase  is  particularly  at  the  ex- 
pense of  the  large  intestine,  the  tumor  will,  by  the  time  it  has 
grown  large  enough  to  be  felt  by  palpation,  be  found  on  the  left 
side.  It  is  quite  possible  that  in  some  cases  the  ileocecal  valve, 
with  the  apex  of  the  intussusceptum,  may  protrude  from  the 
anus,  and  occasionally  the  apex  may  be  detected  by  digital  ex- 
ploration of  the  rectum  when  actual  extrusion  does  not  take 
place. 

Causes. — Predisposing. — It  is  a  well-assured  fact  that  intussus- 
ception occurs  more  frequently  in  infants  and  children  than  in 
adults,  and  in  males  oftener  than  in  females.  It  has  been  stated 
("  American  Text -book  of  Surgery  ")  that  more  than  50  per  cent, 
of  patients  are  under  ten  years  of  age.  It  is  without  doubt  the 
most  common  form  of  intestinal  obstruction  in  children.  Heush- 
ner  states  that  three-fourths  of  all  cases  of  obstruction  of  the 
bowel  occurring  in  childhood  are  from  intussusception.  The 
probable  reason  for  this  may  be  that  the  colon  during  infancy  is 
of  greater  length  than  in  the  adult,  while  the  mesocolon  is  wider, 
thus  making  easier  a  displacement  of  the  former. 

Exciting  Causes. — The  exciting  causes  of  intussusception  in 
many  cases  are  obscure.  According  to  some  authorities,  a  por- 
tion of  the  bowel  may  suddenly  descend  into  a  more  or  less 
paretic  section  below  it,  or  the  intussusceptum  maybe  drawn  into 
the  intussuscipiens  by  a  more  active  peristaltic  action  of  the  latter. 
Among  other  exciting  causes  may  be  mentioned  a  tumor  of  the 
bowel,  general  lack  of  tone,  such  as  may  occur  from  a  state  of 
poor  nutrition,  chronic  diarrhea,  or  constipation. 

The  postmortem  appearance  of  intussusception  will  show  an 
elongated  tumor,  usually  on  the  left  side  of  the  abdomen.  The 
invagination  will  produce  the  appearance  as  though  the  intestine 
was  abnormally  short.  Above  the  point  of  obstruction  the  intes- 
tine is  usually  dilated  and  filled  with  gas  and  feces,  while  below 
it  is  generally  empty,  or  in  some  instances  may  contain  a  small 


232  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

quantity  of  bloody  mucus.  The  sheath  is  distended  and  fre- 
quently ulcerated,  and  there  may  be  symptoms  of  general  or 
local  peritonitis.  The  intussusceptum  is  described  as  being  com- 
monly of  a  deep-red  color,  unless  gangrene  has  set  in,  when  it  is 
black  or  greenish  black  in  hue.  The  surrounding  serous  layers 
become  in  a  short  time  so  united  under  inflammatory  action  as  to 
prevent  reduction  of  the  invagination.  Perforation  of  the  intes- 
tine from  ulceration  may  take  place,  or  a  stricture  occur  as  a  sec- 
ondary consequence  of  inflammatory  action. 

Symptoms. — The  most  prominent  symptom  of  intussuscep- 
tion is  pain.  The  pain  is  generally  of  sudden  onset,  beginning 
in  the  region  of  the  umbilicus,  and  is  at  first  paroxysmal  and 
very  severe.  Occasionally  it  may  radiate  from  the  back  for- 
ward. As  the  disease  progresses  the  paroxysms  of  pain  become 
merged,  until  finally  it  is  constant.  Each  onset  of  pain  is 
accompanied  by  a  discharge  from  the  rectum  of  a  quantity  of 
mucus  and  blood.  In  infants  and  young  children  the  symptoms 
are  more  acute  than  in  older  children,  and  the  pain  is  more  par- 
oxysmal in  type.  Between  the  attacks  the  child  is  quiet,  but 
while  the  paroxysm  is  in  progress  the  patient  screams  and 
assumes  the  characteristic  position  of  intense  abdominal  pain — 
namely,  the  dorsal  position  with  the  thighs  drawn  up  on  the 
abdomen  and  the  legs  flexed  against  the  thighs.  Nausea  and 
vomiting  appear  early  as  symptoms,  and  are  frequently  most 
exhausting.  The  vomited  matter  consists  first  of  the  contents 
of  the  stomach,  but  later  frequently  becomes  stercoraceous. 
Rectal  tenesmus  of  severe  type  is  generally  present  The 
abdomen  is  distended  and  tympanitic,  and  on  the  left  side,  usu- 
ally in  the  iliac  region,  will  be  found  a  tumor  which  is  often 
quite  well  marked  and  is  associated  with  a  corresponding  flat- 
tening on  the  right  side  of  the  abdomen.  Extreme  tenderness  is 
manifested  over  the  seat  of  the  tumor,  although  the  entire  abdo- 
men is  tender  to  the  touch.  This  is  especially  the  case  in  the 
later  stages  of  the  disease  or  when  peritonitis  has  set  in.  The 
pulse  is  quickened  and,  as  the  condition  progresses,  has  all  the 
characters  of  the  pulse  of  abdominal  inflammation.  The  tem- 
perature is  raised  usually  to  about  101  °  to  103°  F.  (38.3°  to  39.4° 
C.).  The  mind  is  clear  ;  the  countenance,  while  generally  tran- 
quil between  the  attacks  of  pain,  will,  if  the  condition  con- 
tinues for  some  time,  assume  the  peculiar  pinched  expression 
always  seen  in  peritoneal  inflammation.  The  amount  of  tym- 
panites is  only  moderate,  and  indeed  may  not  be  present.  There 
is  only  one  sign  which  is  frequently  noticed — namely,  the  de- 
pression in  the  right  iliac  fossa.  This  is  sometimes  known  as  the 


INTESTINAL    OBSTRUCTION.  233 

sign  of  Dance  (signe  de  Dance).  The  symptoms  may  subside 
gradually  if  the  attack  progresses  to  a  favorable  termination. 
When  the  pain  ceases  suddenly,  it  is  usually  a  sign  that  gangrene 
has  occurred  in  the  constricted  portion  of  the  bowel  ;  this  may 
be  followed  by  a  discharge  of  the  gangrenous  portions  and  a 
subsequent  recovery.  Very  frequently  a  sudden  break  in  the 
temperature,  accompanied  by  cessation  of  pain  and  rapid,  thready 
pulse,  points  to  the  onset  of  collapse  and  death.  Partial  or 
entire  suppression  of  urine  may  occur. 

Diagnosis. — Intussusception  can  be  differentiated  from  :  (i) 
Colic  ;  (2)  enteritis  or  dysentery ;  (3)  fecal  impaction ;  (4) 
appendicitis.  From  colic  it  may  be  distinguished  by  the  vomit- 
ing, particularly  when  this  assumes  the  stercoraceous  character. 
The  special  diagnostic  point,  however,  is  the  tumor  on  the  left 
side  of  the  abdomen.  The  bloody  mucous  discharge  is  present 
in  intussusception  and  not  in  colic.  The  general  severity  of  the 
symptoms  seen  in  intussusception  will  also  aid  in  the  diagnosis. 
From  enteritis  intussusception  is  to  be  distinguished  by  the 
presence  of  bloody  discharge  in  the  latter,  the  continuance  of  the 
fever,  and  the  presence  of  a  tumor.  In  dysentery  there  may  be 
a  blood-streaked  diarrhea,  but  the  violent  attacks  of  pain  and  the 
general  symptoms  of  peritoneal  involvement  are  absent.  Impac- 
tion of  feces  can  be  diagnosticated  by  the  total  absence  of  the 
general  symptoms  of  intussusception,  and  by  the  fact  that  the 
tumor  produced  by  the  greatly  distended  bowel  is  on  the  right 
side  of  the  abdomen.  Appendicitis  may  be  distinguished  by  the 
presence  of  the  tumor  in  the  right  side  at  McBurney's  point. 
About  this  will  be  grouped  the  maximum  of  intensity  of  the 
tympanites  and  abdominal  tenderness.  The  general  abdominal 
symptoms  of  an  appendicitis  which  has  existed  for  some  time  are 
generally  those  of  suppurative  peritonitis. 

Prognosis. — The  outlook  for  a  fortunate  termination  without 
operation  is  very  unfavorable.  In  this  class  of  cases  the  best 
chance  for  recovery  is  when  the  invaginated  portion  of  the  intes- 
tine sloughs  and  is  passed  by  the  rectum.  According  to  Treves, 
the  mortality  in  133  cases  in  which  original  operations  were  per- 
formed for  invagination  was  72  per  cent.  In  cases  where  reduc- 
tion was  tried  and  was  found  to  be  easy,  the  mortality  was  30  per 
cent.  ;  or  in  difficult  cases  of  reduction  it  was  placed  at  91  per 
cent.  The  best  prognosis  is  in  those  cases  which  are  operated 
upon  early  in  the  disease.  In  chronic  intussusception  the  prog- 
nosis is  very  gloomy. 

Treatment  of  Intussusception. — When  unrelieved,  the  con- 
dition is  so  rapidly  fatal  in  children  that  no  delay  whatever  should 


234  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

be  permitted  after  the  diagnosis  is  established,  and  prompt 
attempts  made  to  reduce  the  invaginated  bowel.  Even  a  few 
hours'  delay  is  unwise.  An  anesthetic  should  be  given,  the  hips 
raised  up  on  a  pillow,  and  an  injection  of  warm  water  given  with 
a  fountain  syringe.  The  greatest  gentleness  must  be  exercised 
for  fear  of  rupturing  the  gut,  and  the  force  of  the  column  of 
water  regulated  by  raising  or  lowering  the  bag  of  the  syringe, 
each  two  and  a  half  feet  of  elevation  representing  about  one 
pound  of  pressure  to  the  square  inch.  Injections  of  warm  water 
containing  a  teaspoonful  of  salt  to  the  pint  or  of  warm  olive  oil  are 
also  beneficial  in  aiding  the  reduction  of  the  intussusception. 

Inflation  of  the  bowel  with  atmospheric  air  administered 
through  a  long  rectal  tube  and  bellows  may  be  used  with  advan- 
tage in  some  cases.  The  inflation  of  the  bowel  with  hydrogen 
gas  or  carbonic  acid  gas  has  been  recommended,  the  former  by 
Senn,  the  latter  by  Ziernsen,  Libur,  and  Jate. 

If  this  is  not  successful,  the  child  may  be  inverted  and  gentle 
manipulation  of  the  abdomen  attempted.  This  measure  should 
never  be  used  after  the  first  twelve  to  twenty-four  hours,  as  by 
that  time,  especially  if  the  constriction  of  the  bowel  be  very  acute, 
softening  of  the  coats  will  have  occurred  and  the  tianger  of 
rupturing  it  is  veiy  great. 

If  this  is  not  successful,  immediate  abdominal  section  must 
be  performed  and  the  invagination  reduced  by  direct  manipula- 
tion. 

All  of  these  methods  of  treatment  have  their  greatest  amount 
of  usefulness  in  the  first  thirty-six  hours  of  the  intussusception. 
The  patient  should  be  allowed  but  little  food,  and  this  should 
be  systematically  given  and  should  consist  of  milk,  concentrated 
broths,  etc.  No  laxative  or  cathartic  medicine  should  be  given 
by  the  mouth.  Alcoholic  stimulants  are  indicated  when  the 
patient  is  in  danger  of  collapse. 

The  best  chances  of  success  in  reducing  the  intussusception 
by  any  of  the  above-mentioned  methods  are  during  the  early 
stages — that  is,  within  the  first  twenty-four  hours.  After  that 
time  the  efforts  of  the  medical  attendant  should  be  directed  to 
sustaining  the  patient,  with  the  hope  that  the  process  of  slough- 
ing and  evacuation  of  the  strangulated  portion  will  occur. 
During  this  time  the  administration  of  opium  is  of  great  im- 
portance. The  patient  should  be  nourished  more  by  nutritive 
enemata  than  by  food  given  by  the  mouth.  The  patient's  thirst 
may  be  relieved  by  small  quantities  of  cracked  ice,  or,  better 
still,  by  rectal  injections  of  water.  To  relieve  the  vomiting,  the 
stomach  may  be  washed  out  by  means  of  the  stomach-tube. 


HERNIA.  235 

Operation  for  Intussusception. — The  abdomen  is  to  be 
opened  in  the  median  line  and  attempts  made  to  reduce  the 
intussusception,  provided  the  condition  of  the  bowel  warrants 
the  belief  that  the  integrity  of  the  intestinal  wall  is  not  destroyed. 
If  the  operation  be  done  early — within  twenty-four  to  forty- 
eight  hours — and  the  constriction  be  not  extreme,  this  may  be 
accomplished.  If,  however,  the  bowel  shows  evidence  that  its 
circulation  has  been  materially  interfered  with  and  that  there  be 
any  suspicion  that  its  vitality  is  lost,  it  should  be  brought  up  and 
attached  to  the  wound  in  the  abdomen,  an  artificial  anus  thus 
being  established.  It  would  seem  inadvisable  to  attempt  an 
immediate  resection  of  the  damaged  portion  of  the  bowel,  as  at 
this  time  children  are  always  in  profound  depression  and  their 
vitality  is  low.  At  best,  children  withstand  the  shock  of  abdom- 
inal operations  badly.  It  is,  therefore,  best  to  relieve  the  imme- 
diate symptom  in  this  way,  leaving  it  to  a  subsequent  time  to 
complete  the  closure  of  the  artificial  anus. 

VOLVULUS. 

The  symptoms  produced  by  volvulus,  or  twisting  of  the  bowel, 
will  depend  to  a  certain  extent  on  the  part  of  the  bowel  in  which 
the  twisting  has  occurred.  Thus,  in  cases  where  the  constric- 
tion is  in  the  small  intestine,  vomiting  will  occur  early  and  be 
persistent  and  severe.  Wahl's  sign,  which  he  considers  diag- 
nostic, consists  in  a  circumscribed  area  of  tympanites  corre- 
sponding to  the  location  of  the  twisting.  It  is  caused  by  the 
distention  of  the  twisted  loop  of  intestine  by  gas.  Volvulus  is 
most  likely  to  occur  in  the  lower  portion  of  the  ileum  and  the 
sigmoid  flexure  of  the  colon,  and  as  compared  with  other  forms 
of  intestinal  obstruction  it  is  rare.  Its  causes  in  many  cases  are 
obscure.  It  has  been  ascribed  to  an  accumulation  of  intestinal 
contents  above  the  constricted  portion  of  the  bowel,  or  in  some 
instances  may  be  produced  by  adhesions  of  a  loop  of  intestine  to 
a  portion  of  the  omentum.  This  condition  is  so  very  rare  in 
children  that  it  is  practically  unknown. 


HERNIA. 

Inguinal  hernia  in  children  may  be  divided  into  three  classes  : 
(i)  The  congenital ;  (2)  the  funicular  ;  (3)  the  encysted,  or  infantile. 

i.  In  the  congenital  form  a  loop  of  intestine  makes  its  way 
through  the  open  funicular  process.  In  cases  where  it  passes 
into  the  scrotum  it  will  frequently  envelop  the  testicle. 


236  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

2.  In  the  funicular  variety  the  hernia  passes  down  the  open 
canal,  but  does  not  envelop  the  testicle  because  of  the  closure 
of  the  funicular  process  above  the  testicle  by  the  tunica  vaginalis. 

3.  The  infantile  form  is  the  rarest  of  the  three  varieties.      In 
this  the  funicular  process  is  closed  above,  but  not  below,  and  the 
intestine  is  encased  in  a  pouch  of  peritoneum,  forcing  its  way 
into  the  process  and  thence  descends  (Rotch). 

Symptoms. — In  male  children  a  soft  round  tumor  will  be 
felt  extending  from  the  internal  abdominal  ring  into  the  scrotum. 
By  proper  manipulation  this  tumor  can  be  easily  made  to  dis- 
appear as  the  gut  passes  into  the  abdomen  through  the  abdominal 
ring.  In  doing  so  it  will  give  the  characteristic  gurgling  sound. 
The  testicle  may  be  difficult  to  outline,  but  it  will  be  found  above 
and  behind  the  tumor.  In  female  children  the  labium  majus  will 
be  distended  by  the  loop  of  intestine,  which  is  generally  quite 
easily  reduced.  Usually  in  both  sexes  the  tumor  consists  of 
intestine  alone,  but  occasionally  some  peritoneum  may  descend 
with  it. 

Diagnosis. — The  condition  with  which  hernia  is  most  likely 
to  be  confounded  is  hydrocele. 

HYDROCELE.  HERNIA. 

1.  Translucent  by  transmitted  light.  I.  Is  opaque. 

2.  Always  dull  on  percussion.  2.  Always  resonant. 

3.  When  reduction  is  possible,  the  fluid  3.  The  hernia  passes  back  quickly  and 

passes  back  slowly  and  noiselessly.  gives    the    characteristic     gurgling 

sound. 

4.  No  impulse  on  coughing.  4.  An  impulse  can  be  felt  when  patient 

coughs. 

5.  The  ring  is  empty.  5.  The  ring  is  filled  with  the  neck  of 

the  tumor. 

It  should  be  remembered  that  these  two  conditions  are  occa- 
sionally associated. 

Prognosis. — The  outlook  for  cure  in  hernia  is  very  good  pro- 
viding the  child  wears  a  properly  fitting  truss  until  the  ring  has 
had  a  chance  to  close.  Strangulation  is  much  rarer  in  children 
than  in  adults. 

The  treatment  should  consist  in  the  prevention  of  constipa- 
tion by  the  use  of  proper  foods  and  medicines.  The  hernia 
should  be  reduced  and  a  proper  truss  fitted. 

The  Radical  Cure  of  Inguinal  Hernia. — For  many  years  past 
various  operations  have  been  devised  for  the  radical  cure  of  in- 
guinal hernia,  but  failures  were  frequent  and  the  risk  to  life  was 
too  great  for  their  general  acceptance.  We  now  have,  in  the 
methods  of  Bassini  and  of  Halsted,  which  are  similar  in  principle, 


PROLAPSE    OF    THE    RECTUM.  237 

the  means  for  effecting  a  radical  cure  of  this  distressing  and 
dangerous  affection. 

These  methods  consist  in  freely  opening  the  inguinal  canal, 
ligating  the  sac,  transplanting  the  spermatic  cord,  and  bringing 
it  out  at  a  point  above  the  internal  ring  ;  then,  by  means  of 
buried  sutures,  firmly  uniting  the  tissues  and  thus  obliterating 
the  normal  inguinal  canal. 

The  results  following  these  operations  in  many  thousands  of 
cases  in  the  hands  of  hundreds  of  operators  throughout  the  world 
have  been  so  uniformly  successful,  both  as  regards  final  and  per- 
manent results,  in  effecting  a  radical  cure,  that  we  are  no  longer 
justified  in  refusing  our  little  patients  the  benefit  of  this  method 
of  treatment. 

While  it  is  true  that  a  large  majority  of  the  cases  of  inguinal 
hernia  in  children  recover  simply  by  the  aid  of  a  properly  fitting 
truss  in  the  course  of  one  or  two  years,  persistence  in  the  use  of 
this  method  should  not  be  carried  beyond  this  period  of  time. 

It  is  not  fair  to  permit  a  child  to  suffer  all  the  discomforts  of 
wearing  a  truss  for  many  years,  and  during  this  time  risk  the 
grave  dangers  of  strangulation,  when  we  have  it  in  our  power,  by 
these  two  safe  methods  of  operative  procedure,  to  effect  a  certain 
and  permanent  cure. 

The  mortality,  when  modern  methods  of  antiseptic  cleanliness 
are  carried  out,  is  almost  nothing — far  less,  indeed,  than  risks  of 
strangulation  which  the  child  runs  with  even  a  perfect  truss. 

FEMORAL  HERNIA. 

In  this  form  of  hernia  the  intestine  passes  under  Poupart's 
ligament  and  makes  its  way  through  the  femoral  canal,  showing 
itself  directly  under  the  saphenous  opening.  In  femoral  hernia 
the  tumor  is  always  on  the  outer  side  of  the  spine  of  the  pubic 
bone.  This  form  of  hernia  is  much  rarer  in  children  than  is  the 
inguinal  form,  and  is  always  acquired,  never  congenital.  The 
treatment  consists  in  the  wearing  of  a  suitable  truss. 


DISEASES    OF    THE     RECTUM. 

PROLAPSE  OF  THE  RECTUM. 

Causes. — Prolapse  of  the  rectum  usually  arises  from  a  condi- 
tion of  atony  following  protracted  diarrhea.  It  is  not  uncommon 
also  in  attacks  of  diarrhea  following  prolonged  periods  of  con- 
stipation. Violent  attacks  of  coughing,  as  in  pertussis,  may  pro- 


238  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

duce  prolapse  of  the  rectum.  The  condition  is  not  uncommon 
in  children  affected  with  chronic  intestinal  catarrh,  and  is  some- 
times seen  following  the  violent  diarrhea  of  milk  infection. 

Symptoms. — The  bowel  can  be  recognized,  appearing  as  a 
tumor  through  the  anus  ;  the  mucous  membrane  is  usually  of  a 
bluish-red  color,  from  the  interference  with  its  circulation. 

The  treatment  consists  in  the  removal  of  the  causes.  Con- 
stipation should  be  prevented  or  relieved  by  the  use  of  enemata ; 
later  the  bowel  movements  should  be  kept  liquid  or  semiliquid 
by  the  use  of  laxatives.  The  prolapse  should  be  replaced  and  a 
return  prevented  by  the  use  of  rectal  injections  or  suppositories 
containing  some  astringent,  such  as  vinegar,  alum,  tannin,  etc., 
or  the  child  should  evacuate  the  bowels  while  lying  down,  using 
pads  or  cloths  to  collect  the  feces. 

The  tone  of  the  intestine  should  be  restored  as  much  as  possi- 
ble by  the  use  of  cold-water  injections  and  by  the  continued  use 
of  astringents  and  tonics,  such  as  strychnin  or  nux  vomica.  Occa- 
sionally it  is  necessary  to  keep  the  bowel  in  place  by  the  use  of 
a  pad  and  T  -bandage. 

The  best  and  most  satisfactory  method  for  treating  surgically 
prolapse  of  the  rectum  is  by  linear  cauterization  of  the  mucous 
membrane  of  the  prolapsus,  extending  well  up  the  bowel,  but 
great  care  must  be  exercised  not  to  interfere  with  the  sphincter 
muscle  and  not  to  cauterize  too  deeply.  The  actual  cautery 
should  be  used.  This  should  be  tried  in  all  cases  before  the 
more  radical  operation  of  excision  be  undertaken.  This  latter 
procedure  should  only  be  performed  by  a  surgeon  of  wide  expe- 
rience, and  if  the  peritoneum  is  opened,  the  danger  to  life  is 
materially  increased. 

RECTAL   POLYPI. 

Polypoid  tumors  of  the  rectum  may  appear  either  in  the 
pedunculated  form  or  as  simple  hypertrophic  growths  of  the 
rectal  mucous  membrane.  They  are  not  at  all  uncommon  dur- 
ing the  early  years  of  life  ;  in  fact  some  authorities  think  they 
are  more  usual  then  than  at  any  other  period.  The  character- 
istic symptom  is  hemorrhage,  which  may  occur  at  any  time,  but 
is  increased  during  evacuation  of  the  bowels,  at  which  time  there 
is  also  great  pain.  Rectal  polypi  are  of  various  sizes  and,  accord- 
ing to  Rotch,  may  be  of  the  myxofibromatous  or  of  the  adeno- 
matous  variety. 

Their  treatment  consists  in  removal  either  by  section  or  by 
twisting  them  off. 


PROLAPSE    OF    THE    ANUS.  239 

Hemorrhoids  and  fistulae  in  ano  are  not  very  common  during 
childhood,  and  their  treatment  is  the  same  as  in  the  adult. 


PROLAPSE   OF   THE   ANUS. 

Prolapse  of  the  anus  may  be  partial  or  complete.  In  the  first 
variety  the  mucous  membrane  is  sufficiently  everted  to  protrude 
beyond  the  sphincter.  In  the  second  there  is  an  invagination 
of  the  rectal  wall  which  may,  in  some  cases,  be  of  considerable 
length. 

Causes. — The  most  common  predisposing  cause  of  prolapse 
is  any  condition  which  lowers  the  tone  of  the  rectal  mucous  mem- 
brane. It  is,  therefore,  very  commonly  found  during  conditions 
of  prolonged  lowered  vitality.  The  absorption  of  fat  in  the 
ischiorectal  region  is  also  a  predisposing  factor,  occurring,  as  it 
does,  in  all  diseases  accompanied  by  great  depression. 

The  most  frequent  exciting  causes  of  anal  prolapse  are  severe 
and  continued  straining  and  bearing-down  efforts  during  attempts 
to  evacuate  the  bowels.  Phimosis,  stricture  of  the  urethra,  and 
stone  in  the  bladder  are  also  given  as  exciting  causes.  It  very 
often  accompanies  the  more  chronic  forms  of  catarrh  of  the  lower 
bowel,  especially  dysentery,  for  the  reasons  which  have  been 
previously  given.  Prolapse  of  the  anus  may  be  found  at  any 
period  of  childhood,  but  is  most  common  during  the  second  and 
third  years. 

Symptoms. — When  the  amount  of  prolapsed  mucous  mem- 
brane is  slight,  a  small  reddish  or  reddish-blue  ring  will  be 
seen  around  the  anal  opening.  This  ring  is,  of  course,  composed 
of  the  mucous  membrane  of  the  rectum.  Its  appearance  will 
usually  occur  during  the  act  of  defecation.  When  a  large 
amount  of  the  bowel  is  prolapsed,  the  tumor  will  be  large  and 
decidedly  corrugated,  the  mucous  membrane  having  a  deep-red 
or  even  a  purplish  hue.  In  most  cases  the  bowel  is  very  easily 
replaced,  but  the  prolapse  will  return  with  each  attempt  to  move 
the  bowels.  The  amount  of  pain  will  vary  considerably,  but  in 
most  cases  it  is  severe  enough  to  give  the  patient  decided  dis- 
comfort. There  will  be  some  tenesmus.  In  cases  where  the 
prolapse  has  existed  for  any  length  of  time  a  considerable 
amount  of  catarrhal  inflammation  is  set  up,  and  the  prolapsed 
portion  of  the  gut  may  become  ulcerated  and  more  or  less 
hemorrhage  take  place. 

Treatment. — The  first  indication  is  to  replace  the  prolapsed 
bowel,  and  this  can  easily  be  accomplished  by  making  gentle 
pressure  upon  it  with  the  finger,  covered  with  oil  or  vaselin. 


24O  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

The  child  should  lie  upon  its  face  across  the  lap  of  a  nurse  while 
this  is  being  done.  To  prevent  its  recurrence,  every  effort  should 
be  made  to  prevent  the  child  from  straining  during  the  act  of 
defecation.  Rectal  injections  of  ordinary  cold  water  will,  in 
some  cases,  act  well  for  this  purpose,  or  injections  of  olive 
oil  are  sometimes  of  use.  In  some  cases,  where  the  mucous 
membrane  is  rather  hard  to  replace,  cold  applications  in  the 
form  of  ice  poultices  or  cloths  soaked  in  cold  water  will  be 
found  helpful.  Frequently  the  bowel  will  prolapse  with  every 
defecation.  In  these  cases  the  child  should  be  made  to  move  its 
bowels  while  lying  on  its  back,  the  buttocks  meanwhile  being 
pressed  together  by  the  nurse.  Holt  recommends  that  older 
children  should  be  made  to  use  an  inclined  seat  placed  at  an 
angle  of  forty-five  degrees,  and  after  the  bowel  is  empty,  the 
patient  is  to  lie  on  his  back  for  half  an  hour  or  more.  Patients 
suffering  from  prolonged  diarrhea  should  have  the  parts  treated 
by  frequent  sponging  of  iced  water  or  by  injections  of  small 
quantities  of  the  same  in  which  tannic  acid,  in  the  proportion  of 
twenty  grains  to  the  ounce,  has  been  dissolved.  Suppositories 
of  opium  and  cocain  are  often  useful,  but  must  be  used  with  care. 
The  addition  of  the  extract  of  belladonna  will  sometimes  add  to 
their  usefulness.  In  some  cases  relief  is  afforded  by  strips  of 
adhesive  plaster,  two  or  three  inches  wide,  placed  tightly  across 
the  buttocks  (Holt).  Rectal  injections  of  iced  water  containing 
five  or  ten  drops  of  tincture  of  nux  vomica,  or  yi-^-  of  a  grain  of 
strychnin  have  been  recommended.  When  the  prolapse  resists  all 
other  methods  of  treatment,  it  has  been  recommended  that  the 
protruding  part  be  touched  with  Paquelin's  cautery. 


FISSURE  OF  THE  ANUS. 

This  condition  may  be  produced  by  bungling  attempts  at 
introducing  the  nozle  of  a  syringe  into  the  rectum,  or  by  irrita- 
tion caused  by  the  presence  of  intestinal  parasites.  The  most 
frequent  cause  is  a  slight  excoriation  of  the  parts  by  efforts  at 
expelling  a  hardened  mass  of  feces. 

Symptoms. — When  the  fissure  is  of  recent  origin,  the  appear- 
ance is  that  of  a  small  opening  at  the  mucocutaneous  orifice  of 
the  anus.  When  the  condition  has  lasted  for  some  time,  the  fissure 
may  appear  as  an  ulcer  with  indurated  margins.  The  fissure  may 
contain  pus  and  even  blood,  both  of  which  will  be  discharged 
during  the  process  of  evacuating  the  bowels.  The  amount  of 
pain  is  very  considerable :  often  so  severe  as  to  prevent  the  child 


ISCHIORECTAL    ABSCESS PROCTITIS.  24! 

from  making  attempts  to  move  the  bowels,  and  from  this  arises 
constipation,  which  aggravates  the  condition. 

Treatment. — The  constipation  should  be  overcome  by  the  use 
of  suitable  remedies,  and  particularly  by  laxative  enemata.  The 
local  treatment  consists  in  touching  the  fissure  with  a  solution  of 
nitrate  of  silver  after  having  washed  it  out  with  some  nonirritat- 
ing  antiseptic  solution.  In  very  severe  cases  it  may  be  necessary 
to  stretch  the  sphincter. 

The  prognosis  is  usually  good. 


ISCHIORECTAL  ABSCESS. 

This  condition  arises  most  commonly  from  inflammation  of  the 
rectum.  Traumatism  may  also  be  a  cause.  In  the  majority  of 
cases  the  abscess  is  small,  circumscribed,  and  superficial.  The 
prognosis  is  generally  good. 

The  treatment  consists  in  the  evacuation  of  the  abscess  under 
antiseptic  precautions. 

HEMORRHOIDS. 

Hemorrhoids  during  childhood  have  the  same  characteristics 
as  in  later  life.  The  most  common  cause  is  chronic  constipation. 

The  treatment  is  the  same  as  in  hemorrhoids  occurring  in 
adults.  They  are  rare  in  children  under  three  years  of  age. 

INCONTINENCE  OF  FECES. 

Inability  to  control  the  bowels  is  not  infrequently  seen  in 
children  whose  powers  of  resistance  are  lowered  from  various 
causes.  Incontinence  of  feces  also  appears  as  one  of  the  symp- 
toms in  the  paraplegia  of  certain  nervous  diseases  or  any  injury 
to  the  spinal  cord. 

The  treatment  should  be  directed  to  the  cause.  When  the 
trouble  is  local,  cure  may  sometimes  be  effected  by  the  use  of 
ergot  given  by  the  mouth  or  by  rectal  suppositories.  Strychnin 
is  a  valuable  corrective  to  the  lack  of  tone. 


PROCTITIS. 

Three  forms  of  proctitis,  or  inflammation  of  the  rectum,  are 

generally  described — namely :  the  catarrhal,  membranous,  and 

ulcerative.     In  the  catarrhal  form  the  pathologic  changes  are 

those  usually  found  in  the  same  condition  in  other  parts  of  the 

16 


242  DISEASES    OF    THE    DIGESTIVE    ORGANS. 

intestinal  tract.  The  mucous  membrane  is  swollen,  of  a  deep-red 
hue,  with  increased  secretion  of  mucus.  In  many  cases  the  mu- 
cous membrane  bleeds  easily.  When  the  condition  is  of  long 
standing,  white  or  yellowish-white  ulcers  are  to  be  found  along 
any  portion  of  the  rectum,  but  their  most  frequent  site  is  im- 
mediately inside  the  sphincter. 

MEMBRANOUS  PROCTITIS  ;  DIPHTHERIC  PROCTITIS. — It  is  prob- 
able that  the  great  majority  of  these  cases  are  due  to  infection 
by  streptococci,  although  a  certain  number  occur  during  a  general 
infection  of  diphtheria.  The  pathologic  changes  are  the  same 
as  those  found  in  the  condition  known  as  membranous  enteritis. 

ULCERATIVE  PROCTITIS. — This  form  of  inflammation  of  the 
rectum  is  characterized  by  the  presence  of  ulcers  occurring  along 
the  mucous  membrane.  These  ulcers  may  be  superficial  or 
deep,  and  are  usually  multiple.  The  condition  is  commonly 
caused  by  the  progression  of  a  catarrhal  inflammation  into  the 
ulcerative  type.  The  depth  of  the  ulcers  may  vary  rather  con- 
siderably. They  may  be  shallow,  involving  only  the  mucous 
membranes,  or  may  extend  deep  down  into  the  muscular  coat. 
In  the  latter  cases  they  very  frequently  become  chronic  and  are 
of  indefinite  duration.  Ulcers  of  the  rectum  may,  also  be  of 
tubercular  or  of  syphilitic  origin. 

Causes. — Proctitis  may  be  produced  by  an  extension  down- 
ward of  an  inflammation  affecting  the  upper  part  of  the  large  in- 
testine ;  or  by  traumatism,  as  from  careless  efforts  at  the  intro- 
duction of  a  nozle  of  a  syringe.  Intestinal  parasites  may  pro- 
duce it,  and  in  female  children  it  may  be  caused  by  an  extension 
of  a  gonorrheal  inflammation  from  the  vagina  or  urethra  or  by 
direct  infection  through  the  anus.  It  occasionally  follows  or 
appears  during  the  course  of  the  acute  infectious  fevers.  A 
very  frequent  cause  is  the  use  of  irritating  drugs,  used  either  by 
injections  or  suppositories  given  with  the  intention  of  relieving 
constipation.  Holt  states  that  he  has  seen  it  produced  in  an 
infant  a  year  old  by  the  prolonged  use  of  glycerin  suppositories. 

Symptoms. — In  the  catarrhal  form  the  stools  are  increased 
in  frequency  and  in  the  force  by  which  the  contents  of  the  bowel 
are  discharged.  In  this  variety  there  is  also  usually  a  discharge 
of  mucus,  either  in  a  liquid  condition  or  in  the  form  of  a  cast, 
sometimes  mixed  with  traces  of  blood  and  preceding  the  discharge 
of  the  fecal  contents  of  the  bowel.  True  hemorrhage  is  rare. 
Tenesmus  is  nearly  always  .present.  Owing  to  the  irritating 
character  of  the  mucus,  the  external  parts  surrounding  the  anus 
become  inflamed.  Prolapse  of  the  mucous  membrane  is  not 
uncommon.  The  symptoms  of  the  membranous  form  are  very 


PROCTITIS.  243 

much  like  those  of  the  preceding  variety,  with  the  exception  that 
the  discharges  from  the  bowel  contain  a  larger  quantity  of  pseu- 
domembrane. 

The  most  marked  symptoms  of  ulcer  of  the  rectum  are  pain 
and  hemorrhage.  The  pain  is  usually  severe,  and  is  referred  to 
the  region  of  the  anus  or  coccyx  or  the  surrounding  parts.  The 
hemorrhage  is  seldom  severe,  although  occasionally  quite  a  large 
quantity  of  blood  may  be  passed.  It  is  usually  clotted  and  will 
accompany  every  movement  of  the  bowels.  In  chronic  cases 
more  or  less  pus  may  be  found  with  each  stool. 

Treatment. — The  indications  for  treatment  are  to  keep  the 
patient  at  rest,  to  aid  the  digestion  as  much  as  possible,  and  to 
relieve  the  local  condition.  When  the  pain  is  severe,  supposi- 
tories or  injections  of  starch  water  and  opium  should  be  used,  or 
cocain  may  be  brushed  over  the  surface  of  the  mucous  membrane. 
Cocain  may  also  be  applied  in  the  form  of  a  suppository.  Bland, 
slightly  alkalme  injections  are  of  great  use.  They  should  con- 
sist of  starch  or  lime-water  or  i  per  cent,  saline  solution.  When 
the  rectal  discharges  are  highly  acid,  the  enemata  may  be  made 
alkaline,  or  alkalies  may  be  given  by  the  mouth.  In  order  to 
decrease  the  quantity  of  the  evacuation  injections  of  saline  fluid 
should  be  given,  and  these  followed  by  enemata  containing  tan- 
nic  acid  in  a  strength  of  ten  grains  to  the  ounce.  A  I  per  cent, 
solution  of  hamamelis  has  also  been  recommended  for  this  pur- 
pose. The  same  treatment  as  is  used  for  the  catarrhal  form  will 
apply  to  the  membranous  variety.  Ulcers  of  the  rectum  are  in 
many  cases  obstinate  and  slow  in  yielding  to  remedies.  The  in- 
dications for  treatment  are  rest  in  bed,  a  bland  diet  largely  made 
up  of  milk,  and  the  injection,  two  or  three  times  a  day,  of  boric 
acid  solution.  Local  applications  of  a  solution  of  nitrate  of  silver 
of  the  strength  of  one  or  two  grains  to  the  ounce  may  be  applied 
to  the  ulcer  after  the  bowels  have  been  well  washed  out.  Opium 
should  be  given  if  the  pain  is  excessive. 


CHAPTER  VI. 

DISEASES  OF  THE  PERITONEUM. 


APPENDICITIS. 

It  has  become  a  custom,  by  the  common  consent  of  authori- 
ties, to  apply  the  name  appendicitis  to  inflammations  in  and 
about  the  vermiform  appendix,  notwithstanding  the  fact  that 
inflammation  of  the  cecum,  typhlitis,  and  perityphlitis  until  quite 
recently  received  differential  description  in  text-books.  Clinical 
experience  demonstrates  that  almost  invariably  instances  of  in- 
flammatory conditions  in  the  right  iliac  fossa  have  a  common 
origin  in  the  appendix  vermiformis. 

Etiology  and  Pathology. — The  causes  of  apperfdicitis  may 
be  conveniently  divided  into  predisposing  and  exciting.  Of  the 
predisposing  causes  may  specially  be  mentioned  peculiarities  of 
structure,  both  congenital  and  acquired.  Appendicitis  is  more 
common  during  early  than  late  life,  in  those  who  are  habitually 
or  periodically  constipated,  and  in  those  subject  to  intestinal 
catarrh. 

Among  the  predisposing  causes  may  be  mentioned  departures 
from  the  normal  shape  and  situation  of  the  appendix,  together 
with  conditions  of  feeble  nutrition.  These,  combined  with  irreg- 
ularities in  the  development  of  its  mesentery,  may  tend  to  pro- 
duce a  condition  of  twisting,  as  has  been  pointed  out  by  Broca.* 

Accumulations  of  irritating  or  poisonous  substances  within  the 
appendix,  and  especially  collections  of  feces,  may  be  considered 
as  a  predisposing  rather  than  an  exciting  cause.  Indigestion 
plays  an  important  role  as  a  causative  factor.  Heredity  has 
been  mentioned  as  a  favoring  cause ;  thus,  Roux,  quoted  by 
Dieulafoy,f  says  that  in  his  experience  heredity  shows  this  in 
families  affected  by  gout,  urinary  and  biliary  gravel,  and  diseases 
of  this  nature.  He  has  proposed  to  apply  the  term  appendicular 

*  "Gaz.  Hebd.  de  Med.,"  Paris,  1896,  vol.  XLIII,  p.  1026. 
t  "Clinical  Journal,"  London,  1896,  vol.  VIII,  p.  312. 
244 


APPENDICITIS.  245 

lithiasis  to  the  type  which  produces  this  effect  in  the  canal  of  the 
appendix  in  the  same  manner  as  biliary  lithiasis  does  in  the  gall- 
bladder. While  it  is  not  possible  as  yet  to  place  much  signifi- 
cance upon  this  theory,  still  the  question  opens  up  a  wide  field 
for  further  observation.  Traumatism  and  the  lodgment  of  foreign 
bodies  may  also  be  considered  under  the  head  of  predisposing 
causes.  Foreign  bodies,  such  as  seeds,  pieces  of  hair,  glass, 
pins,  etc.,  are  probably  occasional  causes.  Exposure  to  cold  and 
wet,  traumatisms,  the  straining  of  the  abdominal  muscles,  and 
abuse  of  astringent  purgatives  have  all  been  described  as  exciting 
causes. 

Bacteriology. — Studies  of  the  diseases  of  the  vermiform  ap- 
pendix invariably  demonstrate  the  presence  of  the  bacillus  coli 
communis  alone,  in  pure  cultures,  or  associated  with  the  strep- 
tococcus pyogenes.  To  account  for  the  assumption  of  virulence 
of  the  otherwise  harmless  bacteria  Dieulafoy  *  insists  that  the 
closure  of  the  canal  is  the  cause  of  this  pathologic  change  in  the 
bacillus.  In  consideration  of  his  theory  it  has  been  found  that 
the  canal  of  the  appendix  may  be  obstructed  by  the  calculus, 
to  which  the  term  "  calculous  appendicitis"  has  been  applied. 
These  calculi  are  usually  formed  singly,  but  occasionally  three  or 
four  are  seen  together.  They  are  made  up  of  a  stercoral  base 
with  a  mixture  of  calcareous  sulphates  and  phosphates  ;  they  also 
combine  chlorids  and  sulphates.  They  are  of  a  brownish  color 
and  variable  consistency.  Section  of  one  of  them  generally  shows 
stratification.  They  exhibit  a  slow,  progressive  development  in 
the  canal  of  the  appendix.  The  lumen  of  the  canal  may  also  be 
obstructed  by  reason  of  a  local  affection  causing  swelling  of  its 
walls.  As  Rendu  f  reports,  the  canal  may  also  be  obstructed 
by  fibrinous  formations.  Lastly,  two  or  more  of  these  factors 
may  be  found  associated  in  causing  the  obstruction.  Laveran 
disagrees  with  Dieulafoy,  |  and  insists  that  the  closure  of  the  ap- 
pendix is  the  result  and  not  the  cause  of  the  inflammation  and  its 
sequence.  However,  the  fact  remains  that  from  the  degenerated 
condition  of  the  cells  of  the  mucosa  of  the  appendix  virulent 
types  of  malignant  bacteria  develop  and  may  penetrate  the  peri- 
toneal cavity,  either  through  a  perforation  or,  as  shown  by 
Klecki,  §  through  the  lymph-spaces  of  the  damaged  intestinal 
walls. 

*  "  Clinical  Journal,"  London,  vol.  VIII,  p.  310. 

t  "  Bulletin  et  Memoires  de  la  Societe  Med.  des  Hopitaux,"  1896,  No.  4,  p.  8l. 

J  "Bulletin  de  la  Academic  de  Med.,"  Paris,  1896,  vol.  XXXV,  p.  461. 

%  "  Annales  de  1'Institute  Pasteur,"  vol.  LIX,  p.  710. 


246  DISEASES    OF    THE    PERITONEUM. 

Morbid  Anatomy. — Inflammation  of  the  vermiform  appendix 
may  be  found  in  any  of  its  classic  stages  ;  thus,  there  are  recog- 
nized the  catarrhal,  ulcerative,  and  the  gangrenous  varieties.  All 
these  really  are  part  of  one  process,  differences  depending  upon 
the  source  and  virulence  of  inflammation.  Any  one  of  these 
forms  may  be  circumscribed  or  diffused.  In  the  catarrhal  variety 
the  walls  of  the  appendix  are  found  thickened  and  hyperemic. 
The  submucosa  and  muscular  coats  are  infiltrated  by  embryonic 
connective-tissue  cells.  The  lumen  of  the  tube  is  filled  with  the 
debris  of  inflammation,  which  is  thus  becoming  narrowed,  and 
finally,  if  the  condition  continues,  the  canal  may  become  oblit- 
erated. The  marked  peculiarity  of  inflammation  of  the  appendix 
is  the  rapid  involvement  of  all  its  coats.  The  catarrhal  stage 
may  end  in  resolution  or  go  on  to  obliteration  of  the  canal  and 
perforation  of  the  tube.  When  ulceration  occurs,  the  source  is 
in  the  base  of  the  muscular  coat.  The  mucous  and  submucous 
tissues  are  for  the  most  part  destroyed.  The  ulcer  may  perforate 
the  appendix  or,  if  healing  occurs,  stricture  of  the  tissues  may 
ensue.  Dilatation  of  the  tube  may  occur  beyond  the  point  of 
obliteration.  In  the  gangrenous  variety,  known  by  some  as 
interstitial  appendicitis,  a  rapid  necrosis  of  all  the  coats  of  the 
gut  takes  place.  In  a  very  large  class  of  cases  there  may  be  no 
foreign  body  contained  in  the  lumen  of  the  appendix  ;  not  infre- 
quently, however,  there  is  found  a  fecal  concretion  teeming  with 
virulent  bacteria.  These,  if  perforation  occurs,  exude  into  the 
peritoneal  cavity,  starting  up  intense  peritonitis.  The  organ  may 
be  partially  or  entirely  necrosed — not  infrequently  the  entire  ap- 
pendix is  detached  by  sloughing.  The  general  peritoneal  cavity 
becomes  walled  off  by  fibrous  adhesions,  the  result  of  extension  of 
inflammation  to  the  peritoneum.  If  perforation  should  occur  before 
this  happens,  diffuse  peritonitis  results;  otherwise  the  fibrinous  exu- 
date,  by  causing  adhesions  between  the  appendix,  intestinal  coils, 
and  the  abdominal  walls,  acts  as  a  barrier  to  general  infection. 
In  most  cases  suppuration  quickly  follows  the  serous  exudation, 
and  a  localized  abscess  is  formed.  This  may  break  into  the  gen- 
eral peritoneal  cavity  or  escape  through  the  intestine,  or  form  a 
fistula  through  the  abdominal  wall.  Retroperitoneal  abscesses 
occur  when  the  perforation  takes  place  along  the  line  of  attach- 
ment of  adhesions.  Hodenpyl  *  calls  attention  to  the  fact  that 
inflammation  of  the  appendix  may  result  from  tuberculous  or 
lymphoid  ulcers,  although  this  is  rarely  seen. 


*  "New  York  Med.  Jour.,"  December  30,  1893. 


APPENDICITIS.  247 

Symptoms. — Appendicitis  may  be  divided  into  two  varieties  : 
the  catarrhal,  the  phenomena  of  which  are  relatively  slight,  cases 
often  escaping  recognition,  and  perforative  appendicitis,  produc- 
ing gravest  appearances  and  effects. 

Appendicitis  in  its  incipient  stage  produces  symptoms  so  ob- 
scure and  varied  in  character  that  they  are  often  either  unrecog- 
nized or,  if  seen,  their  importance  is  not  appreciated.  The  first 
symptom  of  the  disease  is  pain.  Its  occurrence  is  generally 
sudden  and  unexpected  and  may  be  associated  with  a  chill. 
The  pain  varies  in  intensity  from  mild  discomfort  to  extreme 
agony,  and  is  constant ;  in  many  cases  it  may,  however,  be 
intermittent.  At  the  outset  of  the  disease  the  seat  of  pain  may 
be  referred  to  any  area  of  the  abdomen  or,  as  sometimes  happens, 
to  the  whole  abdominal  region.  No  matter  where  it  begins,  in  a 
short  time  it  is  localized  in  the  right  iliac  fossa  or  over  the 
inflamed  appendix.  Tenderness  quickly  manifests  itself  on  the 
right  side,  with  its  point  of  maximum  intensity  in  the  region  of 
the  appendix — that  is,  at  a  point  near  the  outer  edge  of  the  right 
rectus  abdominis  muscle.  Its  position  may  be  described  as 
being  near  the  center  of  a  line  drawn  between  the  umbilicus 
and  the  anterior  superior  spine  of  the  right  ileum.  This  point 
is  frequently  called  McBurney's  point.  In  the  event  of  the 
appendix  occupying  an  anomalous  position,  this  point  of  tender- 
ness will  be  correspondingly  changed.  Resistance  of  the  walls 
of  the  right  iliac  fossa  becomes  first  noticeable.  When  a  con- 
siderable amount  of  tenderness  is  present,  the  right  rectus 
muscle  becomes  retracted  and  tense,  so  as  to  resist  palpation. 
The  abdomen  becomes  distended  and  tympanitic,  and  a  circum- 
scribed swelling  can  be  made  out  a  little  beneath  the  point  of 
greatest  tenderness.  Gentle  palpation  will  reveal  a  tumor  of 
oval  shape  and  some  tenderness,  the  length  being  about  two 
inches.  Over  the  area  of  swelling  the  percussion-note  is  varied, 
this  variation  depending  upon  the  proximity  of  the  swollen 
appendix  and  its  exudate  to  the  abdominal  wall.  In  the  later 
stages  of  the  disease  fluctuation  may,  perhaps,  be  elicited  in  this 
area.  To  guard  these  tender  points  and  give  himself  greater 
comfort,  the  patient  lies  in  the  dorsal  position  with  the  right  leg 
drawn  up.  A  rapid  elevation  of  temperature  is  usual  at  the 
onset.  In  the  beginning  of  the  attack  the  fever  may  reach  102° 
to  104°  F.  (38.9°  to  40°  C.),  but  later  falls  one  or  two  degrees. 
Cases  mild  in  type  may  not  reach  more  than  101°  or  102°  F. 
(38.3°  to  38.9°  C.)  throughout  its  course,  and  normal  or  sub- 
normal temperature  is  not  seldom  found  in  the  severest  cases. 
Continued  high  temperature  points  to  suppuration,  and  a  sudden 


248  DISEASES    OF    THE    PERITONEUM. 

fall,  while  indicating  in  a  certain  number  of  cases  beginning  reso- 
lution, not  infrequently  indicates  perforation.  The  pulse  is  accel- 
erated, the  rapidity  depending  to  a  considerable  extent  on  the 
height  of  the  fever — a  rapid  pulse  with  a  low  temperature  demon- 
strates that  perforation  has  occurred.  Vomiting  is  more  or  less 
constant  from  the  beginning  of  the  attack,  and  occasionally  is  a 
source  of  much  distress.  When  the  attack  proceeds  favorably, 
the  vomiting  usually  subsides  the  first  day  or  two.  When 
peritonitis  occurs,  the  vomiting  returns  and  is  persistent.  The 
patient  is  usually  constipated,  although  diarrhea  may  be  present ; 
it  is  sometimes  seen  in  the  late  stages  of  a  prolonged  attack. 
The  appetite  is  lost ;  the  tongue  is  furred  and  covered  by  a 
brownish  coat ;  thirst  is  generally  present  and  may  be  intense. 
The  urine  is  scanty  and  at  times  may  be  albuminous  ;  in  the 
majority  of  cases  it  is  high  colored.  In  the  early  stages  of  the 
disease  the  patient  may  feel  a  frequent  desire  to  evacuate  the 
bladder.  When  the  attack  proceeds  to  suppuration,  the  condi- 
tion is  indicated  by  rigors,  sweats,  and  considerable  exhaustion. 
In  many  cases,  however,  the  formation  of  an  abscess  is  indicated 
only  by  the  continued  elevation  of  temperature  and  an  increased 
tenderness  over  the  affected  area.  The  tumorous  mass  in  the 
right  iliac  region  increases  in  size,  but  on  account  of  abdominal 
distention  can  only  at  times  be  demonstrated  with  the  greatest 
difficulty.  General  involvement  of  the  peritoneum  may  occur  at 
this  time  from  rupture  of  the  walls  of  the  abscess  precipitating  its 
contents  into  the  peritoneal  cavity,  or  a  general  peritonitis  takes 
place  almost  from  the  first,  caused  by  the  invasion  of  septic 
bacteria  before  local  adhesions  have  been  established.  When 
this  happens,  the  symptoms  are  those  of  a  severe  peritonitis, 
ending  usually  in  collapse,  death  almost  invariably  following. 
A  certain  proportion  of  cases  end  favorably  without  treatment, 
but  in  these  the  symptoms  are  mild  in  type,  with  but  little  pain 
and  a  slight  elevation  of  temperature,  which  gradually,  or 
sometimes  suddenly,  falls  to  normal.  When  the  disease  has 
continued  for  some  time  and  suppuration  has  taken  place,  the 
countenance  assumes  the  characteristic  pinched  expression  seen 
almost  invariably  in  grave  abdominal  diseases.  The  fever  may 
then  assume  a  hectic  type,  and  the  patient  passes  into  a  genuine 
"  typhoid  state."  Infrequently  in  this  class  of  cases  the  tumor 
in  the  right  iliac  region  becomes  boggy.  The  skin  over  it  may 
be  congested  and  slightly  edematous.  There  may  be  pain  in  the 
right  knee  or  ankle.  Edema  of  the  right  leg  may  occur. 

Diagnosis. — The  recognition  of  appendicitis  from  its  onset  is 
of  the  utmost  importance,  and  the  symptoms  most  to  be  relied 


APPENDICITIS.  249 

upon  are  tenderness  of  the  appendix  itself,  muscular  tension  of 
the  right  rectus  muscle,  and  fever.  Accepting  the  views  of 
Richardson,  sudden  excruciating  pain,  becoming  localized  in  the 
right  iliac  fossa,  while  of  great  diagnostic  value  in  the  recogni- 
tion of  appendicitis,  indicates  extension  of  inflammation  to  the 
peritoneum  and  perforation  of  the  appendix  rather  than  giving 
evidence  of  the  incipiency  of  the  disease.  Vomiting  and  diarrhea 
are  early  symptoms,  but  are  of  value  only  when  associated  with 
the  more  important  diagnostic  points  enumerated.  Palpating 
the  appendix  determines  the  amount  of  enlargement  and  also 
the  degree  of  tenderness  which  may  be  present.  Tumefaction 
and  change  in  the  percussion-note  are  not  usually  recognized 
before  the  third  or  fourth  day.  Appendicitis  must  be  differ- 
entiated from:  (i)  Acute  intestinal  obstruction;  this  occurs 
with  considerable  frequency  in  children,  especially  infants,  and 
not  seldom  becomes  a  possibility  to  be  considered  in  making  a 
diagnosis  :  When  the  obstruction  is  due  to  an  intussusception, 
bloody  discharges  from  the  bowel  are  generally  present,  and 
the  tumor,  instead  of  occupying  the  right  iliac  fossa,  is  found 
either  in  the  median  line  or  more  prominently  in  the  left  side. 
The  possibility  also  of  detecting  the  invaginated  bowel  by  rectal 
examination  will  aid  materially  in  the  diagnosis.  (2)  When 
strangulation  of  the  bowel  is  due  to  a  twist  or  volvulus,  the  pain 
is  not  localized,  as  a  rule  ;  constipation  is  also  more  pronounced 
than  in  appendicitis.  Moreover,  in  this  form  of  obstruction,  as 
well  as  in  intussusception,  the  vomiting  is  apt  to  be  stercoraceous 
and  is  persistent.  Besides  this,  where  a  volvulus  occurs  the  ab- 
domen is  generally  distended.  (3)  Obstruction  of  the  bowel  by 
collections  of  feces  in  the  cecum  may  cause  a  low  grade  of  in- 
flammation ;  this  condition  can  be  recognized  by  its  gradual 
development,  the  boggy  feel  of  the  tumor,  which  can  be  felt  as 
an  elongated  mass  lying  in  a  vertical  direction.  There  is  absence 
of  a  localized  point  of  tenderness  and  pain,  and  almost  never 
symptoms  of  perforation.  The  inflammatory  symptoms  are 
less  severe.  (4)  Acute  indigestion  and  enterocolitis  are  excluded 
by  the  absence  in  them  of  tumor,  of  localized  tenderness,  the 
different  character  of  the  vomited  matter,  and  the  continued 
diarrhea  with  mucous  stools.  The  differentiation  is  often  im- 
possible for  a  day  or  two.  (5)  Hip-joint  disease  and  tubercular 
peritonitis  are  mentioned  as  sources  of  possible  error  in  making 
a  diagnosis  of  appendicitis,  but  these  can  be  excluded  usually  by 
strictly  considering  the  history  of  the  case,  the  symptoms,  and 
general  physical  aspects  of  both  the  above  diseases.  However, 
it  is  to  be  remembered  that  either  or  both  of  these  conditions 


25O  DISEASES    OF    THE    PERITONEUM. 

may  possibly  coexist  with  appendicitis,  in  which  case  a  diagnosis 
is  of  grave  moment  and  requires  much  skill.  (6)  In  girls  at  the 
age  of  puberty  an  abscess  of  the  right  ovary  might  be  quite 
difficult  to  differentiate  from  appendicitis  ;  in  fact,  the  diagnosis 
could  only  be  settled  by  vaginal  examination.  However,  it  is 
more  common  to  find  appendicitis  in  males  than  in  females,  and 
besides  this  the  shape  of  the  tumor,  and  the  generally  greater 
severity  of  symptoms  of  appendicitis,  will  aid  in  the  diagnosis. 
It  would  be  well,  however,  in  cases  where  any  doubt  exists,  to 
settle  the  diagnosis  by  vaginal  examination,  by  which  means  the 
inflamed  ovary  can  be  clearly  made  out.  It  may  often  be  im- 
possible, without  opening  the  abdomen,  to  arrive  at  a  correct 
diagnosis. 

CHRONIC  APPENDICITIS. — The  terms  recurrent  and  relapsing 
appendicitis  have  been  used  in  describing  the  return  of  symp- 
toms after  the  first  attack  has  subsided.  One  attack  predisposes 
to  another  in  the  majority  of  cases.  The  inflammatory  process 
of  the  primary  seizure  may  have  entirely  disappeared,  but  with 
the  result  of  leaving  the  appendix  extremely  susceptible  to  the 
slightest  irritation,  so  that  now  and  then  the  patient  will  suffer 
from  a  recurrence  of  the  disease.  The  symptoms  of 'these  re- 
lapses may  be  as  severe  as  the  original  onset,  but  as  a  general 
rule  they  are  milder  in  type  ;  however,  the  possibilities  are  always 
grave.  On  the  other  hand,  the  primary  inflammation  may  sub- 
side into  a  latent  or  subacute  form,  causing  a  constant  discomfort 
to  the  patient.  In  these  cases  there  is  an  exacerbation  of  symp- 
toms at  short  intervals.  The  term  relapsing  appendicitis  has 
properly  been  applied  to  this  latter  case. 

Treatment. — Absolute  rest  in  bed,  applications  of  external 
heat  in  the  form  of  poultices  of  flaxseed  or  hops,  with  hot-water 
bags  at  the  side  to  keep  the  poultices  warm.  Cold,  in  the  form 
of  an  ice-bag  kept  constantly  applied,  is  very  useful.  No  opium 
whatever  should  be  given  for  the  relief  of  pain,  as  this  and  the 
tenderness  are  our  only  guides  for  the  need  of  active  surgical 
intervention.  Opium  masks  this  symptom,  prevents  peristalsis, 
and  checks  secretions  from  the  intestines  and  kidneys.  The 
bowels  must  be  freely  but  gently  opened  as  soon  as  possible.  If 
the  stomach  is  not  too  irritable,  salines  should  be  given  in  fre- 
quent doses  every  two  hours  until  free  purgation  has  been  accom- 
plished. If  the  vomiting  is  constant  or  the  stomach  unable  to 
retain  the  saline,  calomel  in  small  doses,  every  hour,  should  be 
administered  until  the  desired  results  have  been  obtained.  If, 
after  a  number  of  hours,  the  calomel  does  not  produce  a  free 
evacuation  of  the  bowels,  an  enema  of  hot — very  hot — soap  and 


APPENDICITIS.  251 

water,  to  which  some  glycerin  and  magnesium  sulphate  have 
been  added,  may  be  administered,  to  unload  the  lower  bowel  and 
thus  start  the  intestinal  action. 

The  question  of  pulse  and  temperature  is  of  comparatively 
little  importance  in  determining  the  need  for  surgical  interference, 
as  both  may  continue  high,  and  if  no  opium  has  been  given,  the 
local  pain  and  tenderness  diminish. 

A  sudden  relief  from  pain  and  a  low  temperature  but  high 
pulse-rate  indicate  perforation  of  the  appendix  and  a  probable 
infection  of  the  general  peritoneal  cavity. 

Of  course,  a  very  large  number  of  cases  recover  from  the 
effects  of  the  first  acute  attack  by  these  simple  measures  of 
treatment,  but  it  is  absolutely  impossible  to  take  any  number 
of  days  or  hours  as  a  guide  for  the  necessity  for  surgical  inter- 
ference. The  amount  of  infection  of  the  appendix  may  be  so 
great  that  gangrene  and  perforation  may  occur  as  early  as  in 
from  fifteen  to  twenty  hours  after  the  first  signs  of  pain,  while, 
on  the  other  hand,  the  progress  of  the  disease  may  be  less 
rapid  in  its  development,  and  several  days  may  elapse  before 
these  changes  exist. 

When  the  symptoms  persist  after  free  purgation,  the  pain, 
tenderness,  and  resistance  on  palpation  in  the  right  iliac  fossa 
increase  rather  than  diminish,  no  time  should  be  lost  in  attempt- 
ing further  medical  methods  of  treatment.  The  abdomen  should 
be  opened  and  the  diseased  appendix  removed. 

Evidence  of  abscess,  unless  it  is  absolutely  circumscribed, 
demands  immediate  incision  and  drainage.  It  is  not  wise  to 
make  too  prolonged  a  search  for  the  appendix  in  the  abscess 
cavity,  for  by  so  doing  the  thin  wall  of  lymph,  which  is  nature's 
method  of  protecting  the  surrounding  tissues  from  infection,  may 
be  readily  broken  through  and  a  general  peritoneal  infection 
be  inflicted. 

If  a  general  peritonitis  is  present,  operative  interference  is  still 
more  urgently  demanded,  and  with  fair  chances  of  success  if  the 
intestines  are  not  already  paralyzed  by  the  infecting  process.  In 
the  latter  condition  of  affairs  death  is  almost  certain  no  matter 
what  course  is  pursued. 

If  the  general  peritonitis  is  extensive,  with  pockets  of  pus  here 
and  there  among  the  intestines,  an  incision  should  be  made  in  the 
left  iliac  fossa  as  well,  and  the  whole  abdominal  cavity  flushed 
with  sterile  salt  solution,  directing  the  stream  of  water  from  one 
side  and  allowing  it  to  flow  through  the  opening  on  the  other. 
Drainage  by  gauze  and  rubber  tubing  is  necessary,  no  attempt 
being  made  to  close  the  abdominal  openings  by  sutures. 


252  DISEASES    OF    THE    PERITONEUM. 


TUBERCULOSIS  OF  THE  PERITONEUM. 

Tubercular  peritonitis  is  of  frequent  occurrence  in  childhood, 
and  in  the  majority  of  cases  is  secondary  to  a  primary  focus, 
which  is  oftenest  a  tubercular  infection  of  the  mesenteric  glands. 
Munsterman,  out  of  2837  autopsies,  and  Boschke,  in  226  cases  of 
tubercular  peritonitis,  claim  only  to  have  discovered  one  and 
two  respectively  of  primary  tuberculosis  of  the  peritoneum.  The 
lymph-channels  have  been  proved  the  common  carriers  for  the 
transportation  of  the  bacilli  from  some  distant  or  near  focus,  such 
as  a  tubercular  intestinal  ulcer  or  a  caseous  degeneration  of  a 
mesenteric  gland.  '  The  genital  tract  of  the  female  occasionally 
offers  a  mode  of  infection,  as  is  illustrated  by  the  frequently 
quoted  case  of  Vierrordt :  A  girl  six  and  a  half  years  old  devel- 
oped tubercular  peritonitis  while  suffering  from  vaginal  discharge 
in  which  the  tubercle  bacillus  was  found.  A  good  recovery  was 
made  after  eliminating  the  vaginal  focus  of  infection.  R.  Abbe 
calls  attention  to  the  probability  of  milk  food  acting  as  a  carrier  of 
the  bacillus,  and  suggests  possible  penetration  of  the  intestinal 
follicles  by  the  bacilli  as  the  most  reasonable  method'  for  their 
entrance  in  certain  cases  in  which  no  other  invading  focus  can  be 
found. 

Pathology. — Tuberculosis  of  the  peritoneum  may  be  but  a 
part  of  a  general  miliary  infection  which,  according  to  Zeigler, 
is  evidenced  merely  by  gray  translucent  tubercles  of  small  size 
dotting  the  entire  surface  of  the  peritoneum,  but  without  ex- 
tensive inflammation.  There  may  be  some  slight  injection  of  the 
membrane,  the  latter  being  generally  transparent,  smooth,  and 
glistening.  In  the  form  under  discussion,  in  which  the  tuber- 
culous process  predominates  in  the  peritoneum,  inflammatory 
changes  take  place,  leading  to  the  formation  of  a  liquid  exudate. 
The  peritoneum  is  thickened  and  opaque,  connective  tissue  being 
quickly  developed,  causing  this  density.  Adhesions  of  the  intes- 
tines, numerous  tubercles,  and  caseous  deposits  are  to  be  found 
embedded  in  the  infiltrated  peritoneum.  These  are  often  concealed 
by  the  newly  formed  fibrous  tissues.  The  exudate,  which  varies 
generally  in  quantity,  may  be  composed  entirely  of  serum,  or,  on 
the  other  hand,  may  contain  fibrin,  pus-cells,  and  occasionally 
blood-corpuscles.  Perforation  of  the  intestines  or  abdominal 
wall  may  take  place.  The  process  ends  in  either  absorption  of 
the  inflammatory  exudate  with  caseous  metamorphosis  of  the 
debris,  or  the  infective  process  may  appear  in  other  organs  and 
end  life. 


TUBERCULOSIS    OF    THE    PERITONEUM.  253 

Symptoms. — The  symptoms  will  depend  upon  the  character 
of  the  pathologic  process  existing  in  the  peritoneum.  If  the  dis- 
ease is  but  a  part  of  a  general  miliary  tuberculosis,  the  attack  is 
of  sudden  onset  and  the  symptoms  are  those  of  acute  general 
peritonitis,  except  when,  after  a  short  intermission  of  symptoms, 
a  fresh  outburst  occurs.  The  fever,  which  is  generally  of  true 
hectic  character,  may,  after  a  time,  completely  subside,  but  fol- 
lowing this  reduction  of  temperature  there  is  no  improvement  in 
the  general  health.  Emaciation  becomes  marked,  and  from  the 
coalescence  and  adhesions  of  the  intestines  emesis  and  obstinate 
constipation  supervene.  The  infection  being  general,  death 
usually  results  from  the  more  acute  process  in  the  lungs.  On  the 
other  hand,  when  the  peritoneum  has  become  infected  from  the 
navel,  a  mesenteric  gland,  or  an  intestinal  ulcer,  the  picture  pre- 
sents a  slow,  wasting  disease  almost  identical  in  nature  with 
chronic  peritonitis  from  other  causes,  differing,  however,  in  the 
fact  that  the  febrile  symptoms,  which  at  first  are  hardly  percept- 
ible, soon  become  prominent,  manifesting  themselves  by  slight 
exacerbations  of  the  temperature  in  the  evening.  Accompany- 
ing this  rise  of  temperature  there  are  generally  night-sweats, 
the  abdomen  is  extremely  prominent,  and  may  or  may  not  be 
tender.  The  bowels  may  be  constipated,  although,  as  a  rule, 
diarrhea  is  present.  This  latter  symptom  is  likely  to  occur  in 
paroxysms.  Meteorism  is  marked.  The  pulse  is  weak  and 
small,  and  obstruction  to  the  intra-abdominal  circulation  is  made 
manifest  by  enlargement  of  the  external  abdominal  veins.  The 
little  patient  is  peevish  and  much  emaciated.  The  thoracic 
organs  are,  as  a  rule,  free  from  infection.  Death  results  from 
hemorrhage,  occlusion  of  the  intestines,  strangulation,  marasmus, 
general  tuberculosis,  or  from  exhaustion. 

Diagnosis. — This  is  based  upon  the  character  of  the  tempera- 
ture, the  pain,  the  extreme  emaciation,  and  diarrhea.  Ascites, 
chronic  peritonitis,  and  abdominal  tumors  must  be  differentiated. 
Many  eminent  surgeons  claim  that  a  diagnosis  before  abdominal 
section  is  but  speculation. 

Prognosis. — From  a  medical  standpoint  the  prognosis  is 
extremely  unfavorable.  Von  Striimpell,  Kiirze,  and  Ziemssen 
teach  that  tubercular  peritonitis  always  ends  in  death,  and 
Baginski  claims  never  to  have  seen  a  child  survive  an  attack 
of  this  disease.  From  a  surgical  standpoint  the  outlook  is  con- 
siderably more  favorable.  Undoubtedly  under  suitable  condi- 
tions, by  surgical  methods,  the  tubercular  process  may  be 
arrested,  as  is  attested  by  reports  from  such  authorities  as  Hal- 
sted,  Koenig,  and  others. 


254  INTESTINAL    PARASITES. 

Treatment. — The  medical  treatment  is  the  same  as  that  of 
chronic  peritonitis,  together  with  the  general  treatment  of  tuber- 
culosis. The  indications  for  an  incision  and  drainage  of  the 
abdominal  cavity  are  imperative  in  all  suitable  cases,  as  the  best 
results  have  been  obtained  from  this  method  of  treatment. 


INTESTINAL  PARASITES. 

The  parasites  which  most  frequently  infest  the  intestinal  tract 
of  infants  and  children  are  the  oxyuris  vermicularis,  or  the  pin- 
or  thread-worm,  the  ascaris  lumbricoides,  or  round-worm.  Two 
species  of  tapeworm  are  also  recognized,  the  taenia  medio- 
canellata,  or  beef  tapeworm,  and  the  taenia  solium,  or  pork  tape- 
worm ;  the  trichocephalus  dispar  is  also  occasionally  met  with. 
None  of  these  parasites  are  peculiar  to  infancy  or  childhood. 
The  pin-  and  round-worms  are,  however,  so  frequently  found 
during  the  earlier  years  of  life  that  they  are  classed  among  the 
parasites  peculiar  to  children.  The  tapeworm,  also,  is  not  in- 
frequently found  in  intestines  of  children,  but,  as  a  rule,  it  does 
not  appear  in  as  young  children  as  do  the  other  intestinal  para- 
sites. 

OXYURES  VERMICULARES  are  small  worms  of  a  pinkish-white 
color  and  fusiform  shape,  which  inhabit  the  rectum,  the  large 
intestine  throughout  its  entire  length,  and  the  lower  part  of  the 
small  intestine.  The  female  of  this  parasite,  which  exists  in 
greater  numbers  than  the  male,  measures  from  about  half  an 
inch  in  length,  the  male  being  about  one-half  as  large  as  the 
female.  The  female  is  to  be  distinguished  by  its  more  slender 
and  tapering  shape,  as  well  as  by  its  greater  length.  To  the 
unassisted  eye  they  somewhat  resemble  small  pieces  of  white 
thread ;  hence  their  name.  With  a  low-power  objective  the 
uterine  ducts  will,  in  the  female,  be  seen  to  contain  numerous 
ova,  these  being  ovoid  in  shape,  about  0.053  /"  in  length  and 
0.028  {*  in  breadth.  The  most  common  symptom  denoting 
their  presence  is  a  constant  itching  around  the  anus.  This  irri- 
tation increases  at  night,  and  particularly  when  the  child  is  in 
bed.  In  girls  the  same  irritation  appears  at  the  entrance  of  the 
vagina,  and  the  parasites  themselves  may  be  found  here  as  well 
as  on  the  buttocks  near  the  anal  opening.  From  the  irritation 
caused  by  their  presence  a  true  vaginitis  of  catarrhal  type  may 
be  set  up. 


OXYURES    VERMICULARES.  255 

The  Mode  of  Infection. — The  original  ovum  is  probably 
carried  to  the  mouth  by  toys,  food,  vegetables,  drinking-water,  or 
on  the  fingers  of  those  previously  infected,  and  each  ovum  brings 
forth  a  fully  developed  worm.  Very  soon  the  irritation  produced 
by  the  worm  causes  the  child  to  scratch  about  the  anus,  and 
numerous  ova  are  thereby  lodged  under  the  finger-nails,  to  be 
taken  with  the  food.  It  is  a  curious  fact  that  the  presence  of 
the  worm  does  not  cause  irritation  unless  it  is  in  the  lower  part 
of  the  rectum,  near  the  anus.  Other  than  the  intense  itching 
there  are  no  absolutely  characteristic  symptoms  which  would 
point  to  the  presence  of  the  pin-worm.  The  parasites  themselves 
may  be  frequently  found  around  the  anus  and  about  the  vaginal 
opening  of  little  girls.  When  the  vagina  becomes  infested  with 
them  there  is  set  up  a  vaginitis,  accompanied  by  a  very  free  dis- 
charge of  mucus,  which  may  occasionally  be  tinged  with  blood, 
caused  by  the  continued  scratching.  From  the  same  cause  the 
anal  region  and  buttocks  may  become  excoriated,  and  later  a 
genuine  eczema  may  make  its  appearance.  If  the  cause  is 
long  continued,  the  appetite  becomes  capricious,  the  child  loses 
flesh,  becomes  nervous,  has  dark  circles  under  the  eyes,  does 
not  sleep  well  at  nights,  and,  as  in  all  other  species  of  digestive 
irritation,  is  very  apt  to  pick  at  the  nose.  Various  other 
nervous  symptoms  may  appear,  such  as,  possibly,  chorea  and 
attacks  of  fainting.  The  diagnosis  should  be  based  on  the  dis- 
covery of  the  worms  themselves.  There  are  very  few  diseases 
with  which  they  could  be  confounded,  except  chronic  gastro- 
intestinal catarrh  and  mucous  disease,  both  of  which  have  more 
clearly  defined  symptoms.  An  enema  given  will  scarcely  fail  to 
bring  away  enough  of  the  parasites  to  make  the  diagnosis  plain. 
In  female  children  the  irritation  of  the  vagina  may  be  confounded 
with  specific  vulvovaginitis,  but  the  character  of  the  discharge 
and  the  finding  of  the  parasites  will  not  long  leave  the  diagnosis 
a  doubtful  question. 

Treatment. — The  first  indication  for  treatment  is  to  cleanse 
the  bowels  thoroughly  of  the  worms  and  the  mucus  that  sur- 
rounds them.  This  is  best  done  by  the  administration  of  from 
one  to  three  grains  of  calomel,  in  combination  with  from  one  to 
three  grains  of  resin  of  scammony  (dose  for  a  child  of  eight 
years).  Remedies  such  as  spigelia,  santonin,  and  others  of  the 
same  class  are  often  indicated.  These  should  be  given  by  the 
mouth,  in  combination  with  calomel  or  any  agent,  such  as  sul- 
phate of  magnesia,  which  will  produce  free  watery  movements. 
Once  a  day  the  rectum  should  be  washed  out  with  a  copious 
enema  of  cool,  weak  soapsuds,  and  a  soft-rubber  catheter  should 


256  INTESTINAL    PARASITES. 

always  be  used  in  giving  the  enema  instead  of  the  ordinary 
syringe  nozle,  in  order  that  the  liquid  may  flow  as  high  up 
in  the  bowel  as  possible.  A  very  useful  formula  to  be  given  by 
the  mouth  is  the  following  : 

Calomel, .     >^  to  I  grain 

Bicarbonate  of  soda, I 

Santonin, Vz  to  I      " 

Podophyllin, ^  " 

SlG. — To  be  repeated  every  night  for  two  or  three  nights  (for  a  child  nine 
to  twelve  years  of  age). 

When  relaxation  of  the  rectum  is  present,  injections  of  com- 
mon salt  solution,  quassia,  alum,  tannin,  etc.,  may  have  a  certain 
effect  in  relieving  this  condition.  Dr.  Charles  W.  Townsend,  of 
Boston,  recommends  the  injection  of  one  dram  of  sulphate  of  iron 
to  one  pint  of  infusion  of  quassia  for  this  purpose.  In  order  to 
prevent  the  transferring  of  the  ova  by  means  of  the  finger-nails, 
the  hands  of  the  patient  should  be  carefully  washed  in  soapsuds 
after  each  movement  of  the  bowels,  and  the  parts  around  the 
anus  should  be  well  cleansed  with  soap  and  water  and  smeared 
with  an  antiseptic  ointment.  When  eczema  is  present,  the  fol- 
lowing ointment  may  be  used,  both  for  its  antiseptic  properties 
and  to  allay  the  irritation  caused  by  the  parasites  : 

Boric  acid, I  dram 

Acetanilid, 20  grains 

Oil  of  rose,      5  drops 

Vaselin, 2  ounces. 

It  should  be  remembered  that  all  means  for  the  transference 
of  the  ova  should  be  removed  as  far  as  possible.  The  bedcloth- 
ing  should  be  boiled  and  washed — in  fact,  all  the  clothing  and 
furniture  used  by  the  patient  should  be  carefully  antisepticized. 

ASCARIS  LUMBRICOIDES  (Rowid-worms]. — The  females  of  the 
round-worms  measure  from  four  to  twelve  inches  in  length,  and 
are  of  a  grayish  or  reddish- white  color.  They  somewhat  resem- 
ble earth-worms,  from  which,  however,  they  can  be  distinguished 
by  their  color  and  the  fact  that  the  earth-worm  has  plainly 
marked  segments  which  can  be  seen  on  close  examination.  The 
ascaris  is  occasionally  found  in  the  small  intestines  in  large  num- 
bers. They  are  much  given  to  wandering  about,  and  may  pass 
into  the  stomach,  into  the  large  intestine,  or  gall-bladder.  It  is 
said  that  in  rare  instances  they  have  been  found  in  the  esophagus, 
in  the  pharynx,  mouth,  or  even  in  the  lungs.  The  female  can 
be  distinguished  from  the  male  by  its  greater  size  ;  it  is  also  more 
slender  than  the  male,  the  tail  being  straight  and  tapering,  while 


ASCARIS    LUMBRICOIDES.  257 

that  of  the  male  is  curved  and  blunter.  The  ova  are  produced 
in  immensely  large  quantities  and  are  passed  off  in  the  feces,  in 
which  they  can  without  much  difficulty  be  discovered  by  exami- 
nation with  a  low-power  objective.  They  are  oval  in  shape,  about 
f^ft  of  an  inch  in  length,  and  have  thick,  transparent  coats, 
within  which  the  dark  granular  contents  of  the  ovum  can  be  seen. 
The  ova,  which  are  extremely  resistant  to  destruction  by  external 
influences,  are  usually  taken  in  by  the  mouth  from  toys,  food,  drink- 
ing-water, or  the  dust  which  adheres  to  the  fingers.  Children, 
in  crawling  or  playing  around  a  room,  and  thus  bearing  on  their 
hands  a  quantity  of  dust  which  in  many  instances  has  come  from 
the  street,  may  thus  carry  the  eggs  of  the  parasite  into  the  sys- 
tem. It  is  certain  that  ascarides  are  less  frequently  found  among 
the  better  class  of  people  in  whom  the  laws  of  cleanliness  are 
more  strictly  carried  out  than  among  the  poor  and  those  of 
uncleanly  habits.  They  are  much  rarer  now  in  all  classes  than 
they  were  a  score  of  years  ago.  Constant  bathing,  with  proper 
care  of  the  finger-nails  of  children,  and  seeing  that  their  food  is 
well  cooked,  will  do  much  to  prevent  infection  by  these  parasites. 
The  round-worm  is  much  more  frequently  found  in  children  after 
the  third  year  than  in  infants  or  adults. 

Symptoms. — It  is  certain  that  in  many  cases  large  quantities 
of  these  worms  may  exist  for  a  long  time  within  the  intestinal 
tract  without  producing  any  symptoms  at  all.  As  the  majority 
of  intestinal  parasites  are  found  in  children  whose  digestions 
are  habitually  weakened,  the  lining  membrane  of  whose  intes- 
tines are  continually  coated  with  mucus,  in  which  these  parasites 
thrive,  the  majority  of  the  symptoms  usually  ascribed  to  the 
presence  of  worms  are  due  in  reality  to  a  chronic  state  of  gastric 
or  intestinal  catarrh.  The  classic  symptoms  which  parents  will 
usually  expect  us  to  associate  with  the  presence  of  worms  are : 
A  capricious  appetite,  or  in  some  cases  a  ravenous  desire  for 
food,  unattended  with  any  increase  in  bodily  weight,  or  in  some 
cases  an  absolute  decline  of  it ;  irregular  feverish  attacks  ;  dis- 
turbed sleep  and  bad  dreams,  accompanied  by  grinding  of  the 
teeth  ;  pain  in  the  stomach  after  taking  food,  and  picking  at  the 
nose,  and  very  frequently  the  passage  from  the  bowels  of  large 
quantities  of  mucus,  or,  where  the  parasites  are  actually  present, 
a  number  of  these  or  their  ova.  It  will  be  seen  that  none  of 
these  symptoms  described  is  in  any  way  characteristic  :  any  or 
all  of  them  may  be  found  in  most  forms  of  intestinal  catarrh. 
It  can  not  be  doubted,  however,  that  a  number  of  reflex  nervous 
symptoms  are,  in  susceptible  subjects,  caused  by  the  presence  of 
intestinal  parasites,  and  probably  every  physician  has  met  at 
17 


258  INTESTINAL    PARASITES. 

least  one  or  more  such  cases,  in  which  symptoms  of  severe  ner- 
vous disturbance  have  been  relieved  by  completely  clearing  these 
parasites  from  the  bowels.  A  very  interesting  case  has  been 
reported  by  Townsend  from  the  records  of  the  Boston  Children's 
Hospital,  where  a  girl  four  years  old,  previously  in  good  health, 
was  attacked  by  convulsions  and  nervous  tremors,  which  were 
distinctly  traced  to  a  large  number  of  round-worms  in  the  intes- 
tines. Her  condition  immediately  improved  as  soon  as  the  intes- 
tines were  thoroughly  cleared  of  these  worms,  and  the  symp- 
toms returned  as  soon  as  a  fresh  quantity  of  the  parasites  were 
generated.  There  is  also  some  danger  of  occlusion  of  the  intes- 
tines, due  to  a  simple  mechanical  obstruction  caused  by  large 
masses  of  worms  ;  thus,  in  Hillyer's  case,  in  which  a  weakly 
child  of  five  and  a  half  years  was  attacked  by  severe  abdominal 
pain,  and  upon  being  given  a  dose  of  oil  vomited  a  round-worm. 
The  child  died  on  the  following  day,  and  at  the  autopsy  the 
ileum  was  found  occluded  at  a  point  fifteen  inches  above  the  ileo- 
cecal  valve  by  "  a  tightly  wound  ball  composed  of  eight  round- 
worms  ;  forty-two  worms  in  all  were  found  in  the  intestines. 
Below  the  obstruction  the  intestine  was  empty,  while  it  was  dis- 
tended above."  Round-worms  are  such  wanderers  that  there  is 
no  telling  where  they  may  not  travel  and  set  up  an  irritation  by 
their  presence  ;  thus  they  may  penetrate  the  cystic  or  common 
bile-duct  and  cause  jaundice  by  stopping  the  flow  of  bile. 
Abscess  of  the  liver  has  been  known  to  occur  from  their  having 
penetrated  this  organ.  They  have  also  been  known  to  penetrate 
the  trachea,  or  even  the  lung,  causing  strangulation  or  pulmonary 
gangrene. 

Diagnosis. — As  the  symptoms  are  so  very  unreliable,  a  posi- 
tive diagnosis  can  only  be  made  by  microscopic  examination  of 
the  feces.  With  a  low-power  objective,  one  which  magnifies,  say, 
about  320  to  350  diameters,  the  eggs  will  be  easily  recognized. 
Those  of  the  round-worm  are  to  be  distinguished  from  the  oxy- 
uris,  the  former  being  larger  and  rounder,  while  those  of  the 
oxyuris  or  pin-worm  are  sharp,  smaller,  and  more  oval.  From 
tapeworm  the  ova  of  the  ascaris  are  to  be  distinguished  by  the 
fact  that  the  latter  are  rounder  ;  we  have,  too,  in  tenia,  the  expul- 
sion of  the  segments. 

Treatment. — The  most  successful  treatment  consists  in  the 
administration  of  santonin,  usually  combined  with  calomel  or 
castor  oil.  Of  all  the  drugs  given  to  cause  the  death  and  expul- 
sion of  worms,  santonin  is  probably  the  best.  It  must  be  remem- 
bered, however,  that  it  is  an  extremely  poisonous  drug  and  must  be 
administered  with  great  caution.  The  toxic  symptoms  are  gastro- 


TENIA.  259 

intestinal  irritation,  muscular  tremor,  and  a  sensation  as  if  the 
patient  were  looking  through  yellow  glass.  If  the  poisoning  con- 
tinues, there  will  be  dizziness,  extreme  dilatation  of  the  pupils,  con- 
vulsions, and  finally  loss  of  consciousness.  Santonin  is  best  com- 
bined with  calomel,  from  one  to  three  grains  of  the  former  being 
given  with  one-half  to  one  grain  of  the  latter.  Townsend,  in  the 
"  American  Text-book  of  Diseases  of  Children,"  gives  the  exact 
dosage  of  santonin  as  follows  :  For  two  years  of  age,  ^  to  ^ 
of  a  grain  ;  at  six  years  of  age,  one  grain  ;  and  at  twelve  to 
fifteen  years  of  age,  two  grains.  In  our  own  experience  we  have 
found  this  dosage  to  be  about  correct.  The  child  should  receive 
a  dose  in  the  morning  and  one  at  night,  or  in  some  cases  three 
times  daily.  Some  authorities  recommend  that  a  dose  of  santo- 
nin combined  with  calomel  or  oil  should  be  given  at  night,  to  be 
followed  in  the  morning  by  sulphate  of  magnesia  or  other  saline. 
It  should  not  be  forgotten  that  as  the  patients  who  are  most 
commonly  infected  with  these  worms  are  considerably  below 
the  average  standing  in  bodily  health,  this  condition  should  be 
attended  to.  Tonics  should  be  administered,  and  the  diet  and 
general  hygienic  surroundings  improved  as  much  as  possible.  A 
diet  containing  a  considerable  amount  of  salted  foods  has  been 
recommended  by  some  authorities. 

TENIA  (Tapezvorni). — The  two  species  of  tapeworm  most  com- 
monly seen  are  the  taenia  solium,  found  in  pork,  and  the  beef 
tapeworm,  or  taenia  mediocanellata.  Another  rare  species 
known  as  the  bothriocephalus  latus  is  sometimes  described. 
Two  other  rarer  forms,  known  as  the  taenia  nana  and  the  taenia 
cucumerina,  are  so  seldom  seen  in  this  country  that  they  will  not 
be  more  than  mentioned.  The  length  of  the  average  tapeworm 
may  be  anywhere  from  twenty  to  fifty  feet ;  they  are  of  a  white 
color,  and  receive  their  name  from  their  resemblance  to  a  piece 
of  ribbon  or  tape.  The  taenia  mediocanellata  and  the  taenia 
solium  are  to  be  differentiated  by  the  shape  of  the  head,  and 
also,  to  some  extent,  by  the  shape  and  size  of  the  segments,  the 
head  of  the  taenia  solium  being  rather  pointed  and  containing 
four  sucking  discs,  surrounded  by  a  circle  of  hooklets.  The 
head  of  the  taenia  mediocanellata  is  much  flatter,  has  four  discs, 
but  no  hooklets.  Both  species  are  composed  of  a  small  head, 
about  the  size  of  that  of  a  pin  or  a  little  larger,  and  an  immense 
number  of  segments.  Each  segment  is  sexually  complete  in 
itself,  or  what  is  known  as  hermaphroditic. 

Diagnosis. — The  diagnosis  can  be  made  by  finding  the  seg- 
ments and  carefully  examining  them  through  the  microscope. 
The  species  can  be  determined  by  the  difference  in  the  shape  of 


260 


INTESTINAL    PARASITES. 


the  head,  already  described.  Microscopically,  it  will  be  seen 
that  in  the  taenia  mediocanellata  the  lateral  branches  of  the 
uterus  are  finer  and  much  more  numerous  than  in  the  taenia 
solium. 

Mode  of  Infection  and  History   of   Development. — The 
eggs  of  the  two  principal  varieties  of  tapeworm  usually  find  their 

way  into  the  intestines 
of  their  human  hosts  in 
the  following  manner  : 
They  are  at  first  most 
probably  contained  in 
manure  or  fertilizer,  and 
thence  are  taken  into 
the  stomach  of  the  ani- 
mals most  commonly 
used  for  food — namely, 
cattle  and  hogs.  Hav- 
ing found  their  way  into 
the  stomach  of  the  ani- 
mal, the  outer  coverings 
of  the  egg  are"  dissolved, 
and  the  embryo  is  set 
free.  The  embryo  then 
pierces  the  stomach  - 
walls,  and,  entering  the 
blood  current,  is  carried 
to  any  part  of  the  ani- 
mal's body,  particularly 
the  muscles,  in  which 
it  buries  itself,  forming 
what  is  known  as  a  cysti- 
cercous  cyst.  Usually 
not  one  but  many  of 
these  cysts  pass  into  the 
circulation  of  the  animal 
at  one  time.  Within  the 
cystthe  embryonic  or  lar- 
val tenia  grows.  These 

cysts  are  extremely  tenacious  of  life,  and  they  have  frequently 
been  known  to  remain  alive  in  the  tissues  of  an  animal  for  four 
or  five  years.  Unless  the  tissue  in  which  they  lie  dormant  is 
taken  into  the  human  stomach,  the  embryo  finally  dies,  and  the 
cyst  becomes  calcified.  If,  however,  the  meat  containing  a  living 
cyst  is  taken  into  the  human  digestive  organs,  the  scolex  grows 


FIG.  25. — HEAD  OF  T/ENIA 
NANA,    VON   SIEBOLD  ; 
WITH  RETRACTED  Ros- 
TELLUM.  —  (  Aft  e  r 
Leuckart.)     X  75- 

A.    An  isolated   hook.    X 
300. 


FIG.     24. —  T>ENIA 
NANA,  VON  SIE- 
BOLD. —  (After 
Leuckart.)     X 
10. 


FIG.  26.— EGG  OF  T/ENIA 
NANA,  VON  SIEBOLD. 
—(After  Leuckart.)  X 
300. 


TENIA. 


26l 


rapidly  into  a  mature  tenia.  The  worm  grows  by  the  develop- 
ment of  those  segments  nearest  the  head,  these  becoming  mature 
as  they  progress  further  from  the  point  of  origin,  and  it  is  from 
these  sexually  mature  segments  that  ova  are  given  off.  The 
worm  makes  its  home  usually  in  the  upper  part  of  the  jejunum, 
or  at  least  it  is  here  that  the  head  is  firmly  attached  to  the 
mucous  membrane  by  hooklets  and  suckers.  The  body,  com- 
posed of  a  vast  number  of  segments,  may  extend  for  any  distance 

along  the  intestine,  depending  on  the 
length  of  the  animal.  Sometimes  it 
may  reach  as  far  as  the  ileocecal  valve. 
The  taenia  solium  is  usually  found 
singly,  while  two  or  more  of  the  taenia 
mediocanellata  are  often  seen  in  a 
single  intestine.  It  is  quite  possible — 
indeed,  it  occasionally  happens — that 


FIG.  27. — T^NIA  SAGINATA,  GOEZE. — 
(After  Leuckart.) 


FIG.    28.  —  CEPHALIC    END    OF 

SAGINATA,    GOEZE.  —  (After   Leuck- 
art.) 
A  in  retracted  and  B  in  extended  state. 


the  eggs  of  the  tenia,  after  having  been  swallowed  by  man,  pass 
through  the  coats  of  the  stomach  in  the  same  way  as  in  the 
animal,  and  develop  a  cysticercous  cyst  in  any  part  of  the  body, 
especially  in  the  subcutaneous  or  intermuscular  connective  tissue 
or  in  the  eye  and  brain  (Townsend).  The  cysticercus  is  extremely 
resistant  to  high  temperatures, and  it  is  usually  byeating  improperly 
cooked  beef  or  pork  that  the  infection  takes  place.  Eating  sausages 
made  of  raw  pork  or  raw  beef  is  a  common  mode  of  infection. 


262 


INTESTINAL    PARASITES. 


Symptoms. — The  first  and  most  common  indication  of  the 
presence  of  a  tapeworm  is  the  finding  of  the  segments  or  proglot- 
tides  in  the  feces.  Besides  this,  there  is  no  regular  sequence  of 
symptoms  denoting  its  presence  any  more  than  in  other  forms 
of  intestinal  parasites.  Frequently  there  may  be  pain  or  sensa- 
tions of  discomfort,  which  are  referred  to  the  region  of  the  um- 
bilicus. The  appetite  may  be  great,  but  is  accompanied  by  a 
gradual  loss  of  bodily  weight.  When  nervous  symptoms  are 
present,  they  are  usually  those  previously  referred  to  in  the  de- 
scription of  the  other  forms  of  intestinal  parasites. 

Treatment. — The  treatment  should  be  aimed  at  dislodging,  as 
quickly  as  possible,  that  part  of  the  worm  known  as  the  head, 

and  during  the  administration  of 
remedies  for  this  purpose  the  feces 
should  be  examined  with  the  great- 
est care  by  the  physician  himself. 
The  success  of  the  treatment  con- 
sists in  the  careful  administration 
of  any  one  of  a  very  few  drugs. 
Whichever  one  of  these  is  used, 
the  method  of  procedure  must  be 
thorough.  A  great  deal  of  the 
success  lies  in  the  patient  carefully 
carrying  out  the  rules  laid  down 
for  him.  The  remedies  most  com- 
monly used  are  pomegranate,  or  its 
alkaloid,  pelletierin  ;  pumpkin-seed, 
kousso,  the  root  of  the  male-fern, 
turpentine,  and  cocoanut.  Of  all 

these,  by  far  the  most  efficient  is  pelletierin.  This  may  be  given 
in  the  form  of  the  tannate,  which  is  an  exceedingly  efficient 
remedy,  although  expensive.  The  dose  of  this  for  an  adult  is 
from  five  to  twenty  grains  ;  the  dose  for  children,  however,  should 
be  regulated  according  to  age.  The  method  of  administration 
of  this  drug  is  as  follows  :  A  preparatory  treatment,  consisting 
of  partial  starvation,  should  be  instituted  for  some  hours  before 
the  teniacide  is  given.  During  this  time  small  amounts  of  food 
which  is  principally  digested  in  the  stomach  should  be  given. 
It  has  been  recommended  that  early  in  the  evening  the  child  be 
given  a  bowl  of.  beef-tea  with  half  a  slice  of  white  bread.  In  a 
little  while  the  patient  should  receive  an  enema  and  be  put  to 
bed.  On  the  following  morning  a  cup  of  beef-tea  should  be 
given,  and  an  hour  after  breakfast  a  full  dose  of  the  anthel- 
mintic  administered,  to  be  followed  in  an  hour  by  a  good  active 


FIG.  29. — HEAD   OF   T/ENIA   SOLIUM. 
ON  THE  RIGHT,  EGG  OF 
SOLIUM. — (Leuckart.) 


TENIA.  263 

cathartic.  Great  care  should  be  exercised  that  when  the  worm 
is  expelled  it  is  not  broken  off  and  part  of  it  left  behind  in 
the  rectum.  To  prevent  this  it  may  be  necessary  to  dilate  the 
sphincter  gently  by  means  of  a  rectal  speculum.  Next  in  effi- 
ciency to  pomegranate  and  its  alkaloids  is  the  oil  of  male-fern, 
oleoresina  aspidii.  The  dose  of  this  drug  for  a  child  of  five 
years  is  a  teaspoonful.  It  may  be  given  in  four  doses  of  fifteen 
or  twenty  grains  each  a  quarter  of  an  hour  apart. 


CHAPTER  VII. 

DISEASES  OF  THE  LIVER. 

Diseases  of  the  liver  are  comparatively  rare  in  childhood,  and 
have  received  singularly  little  attention  at  the  hands  of  syste- 
matic writers  on  pediatrics.  Disorders  of  the  liver  are  more  fre- 
quently due  to  secondary  changes,  usually  preventable,  than 
those  of  almost  any  other  organ.  The  causal  processes  of  these 
operate  over  long  periods  of  time,  and  it  is  a  quality  of  infantile 
tissue  to  escape  many  of  them.  Moreover,  this  very  rarity  limits 
the  possibility  of  any  one  observer  coming  in  contact  with  many 
instances  of  organic  hepatic  disease,  rendering  them  less  ready  to 
invite  much  literary  attention.  In  consequence  of  this  students 
are  not  well  instructed,  and  instances  of  liver  disease,  when  they 
do  occur,  receive  less  recognition  and  attention  than  their  impor- 
tance warrants.  Functional  disorders  of  the  liver  occurring  in 
late  childhood  and  early  adolescence,  however,  we  are  told  by 
Musser,  are  probably  of  much  more  frequent  occurrence  than  we 
are  led  to  believe  from  the  text-books.  Before  taking  up  the 
subject  of  the  various  diseases  separately,  a  few  remarks  as  to 
the  general  symptomatology  of  affections  of  the  liver  are  in 
order. 

In  a  general  way  the  symptoms  of  hepatic  disease  in  childhood 
are  the  same  as  in  the  adult ;  thus  we  have  the  phenomena  point- 
ing to  general  failure  of  health  and  strength ;  there  is  a  loss  of 
appetite  and  other  dyspeptic  symptoms.  The  bowels  are  either 
constipated  or  irregularly  loose.  More  or  less  jaundice  usually 
accompanies  the  condition.  In  certain  diseases  of  this  class 
ascites  is  a  prominent  feature.  Enlargement  of  the  spleen  and 
of  the  veins  of  the  abdomen  are  also  occasionally  seen.  From  the 
congestion  affecting  the  lower  bowel  hemorrhoids  are  frequently 
produced.  In  certain  affections,  particularly  those  accompanied 
by  formation  of  pus  in  the  liver,  chills,  fever,  and  sweats  may 
occur.  Various  nervous  disturbances,  such  as  intense  mental 
depression,  amounting  sometimes  to  an  actual  melancholia,  are 
nearly  always  present.  Pain  is  only  present  in  certain  acute  dis- 
eases, such  as  suppurative  hepatitis,  in  acute  congestion,  and  in 

264 


INSPECTION.  265 

syphilitic  disease  of  the  organ,  especially  where  the  capsule  is 
involved.  When  present,  it  will  be  localized  or  general,  rather 
more  generally  the  former.  It  is  felt  on  the  right  side  of  the 
hepatic  region,  and  may  extend  to  the  right  shoulder.  As  a 
general  rule,  it  is  dull  and  heavy  in  character,  although  in  certain 
forms  of  hepatitis  it  is  sharp  and  cutting,  very  closely  simulating 
that  of  right-sided  pleurisy  or  pleurodynia.  However,  we  know 
that  in  pleurodynia  we  have  immobility,  the  respirations  and 
general  movements  are  painful,  the  parts  affected  being  tender 
when  palpated  or  subjected  to  other  methods  of  examination. 
As  a  general  rule,  also,  there  may  be  rheumatism  in  other  parts 
of  the  body.  In  pleuritis  the  pain  is  distinctly  increased  during 
respiration,  and  is  always  associated  with  pleural  friction  sound. 
Besides  this,  a  cough  of  characteristic  type  always  attends  the 
attack.  Occasionally  the  symptoms  of  perihepatitis  may  so  simu- 
late those  of  pleurisy  affecting  the  right  side  that  it  is  almost  im- 
possible to  tell  them  apart,  but  in  pleurisy,  sooner  or  later,  fluid 
will  be  detected  in  the  cavity  of  the  pleura,  while  in  hepatitis,  of 
course,  no  such  symptom  will  develop.  The  pain  may  also  be 
distinctly  paroxysmal,  as  in  hepatic  colic,  but  this  affection  is 
found  so  rarely  in  young  children  that  it  may  almost  be  left  out 
of  the  question.  Pain  from  liver  disease  is  apt  to  be  constant, 
and  is  most  usually  increased  by  movement  or  pressure.  It  is 
liable  to  extend  upward  along  the  lower  edge  of  the  organ  or 
into  the  epigastrium.  In  hepatic  abscess  the  pain  is  local- 
ized, and  where  the  abscess  has  resulted  from  traumatism,  the 
position  of  pain  corresponds  to  the  point  of  injury.  In  dis- 
ease accompanied  by  enlargement  of  the  organ  sensations  of 
heaviness  and  weight  are  sometimes  experienced  on  the  right 
side. 

During  the  early  years  of  life  the  liver,  in  proportion  to  the 
bodily  weight,  is  much  larger  than  in  the  adult.  The  upper 
border  extends  to  the  fifth,  sixth,  and  seventh  ribs  in  the  mid- 
clavicular,  axillary,  and  scapulary  lines  respectively.  The  lower 
border  can  be  outlined  two  inches  below  the  margins  of  the  ribs. 
The  left  lobe  can  be  outlined  with  considerable  ease,  and  extends 
in  the  median  line  to  within  an  inch  of  the  umbilicus. 

In  order  to  make  a  systematic  examination  of  the  organ  the 
methods  to  be  employed  may  be  divided  into  inspection,  palpa- 
tion, and  percussion. 

Inspection. — In  inspecting  the  abdomen  and  thorax  of  a  pa- 
tient suffering  from  hepatic  disease  little  information  can  often  be 
obtained,  except  in  certain  forms  of  disease.  The  abdomen  may 
be  somewhat  distended,  sometimes  by  flatulence  and,  in  certain 


266  DISEASES    ©F    THE    LIVER. 

affections,  by  ascites.  If  much  enlargement  of  the  liver  is  pres- 
ent, the  lower  third  of  the  right  side  of  the  thorax  and  the  upper 
part  of  the  right  side  of  the  abdomen  may  be  distended,  and  the 
breathing  correspondingly  affected  on  that  side.  Especially  is 
the  latter  the  case  if  much  pain  is  present.  In  abscess  and  hy- 
datid  disease  tumors  may  be  outlined  in  the  left  lobe  and  along 
the  lower  border  of  the  right  lobe.  Occasionally  in  abscess  the 
skin  above  the  affected  area  of  the  liver  may  assume  a  red  color. 
Enlargement  of  the  veins  of  the  abdomen  will  very  frequently  be 
noticed,  especially  in  certain  diseases.  The  position  assumed  by 
the  patient  is  of  some  value  in  diagnosis.  When  lying  down,  the 
patient  will  usually  assume  a  posture  on  the  right  side,  with  legs 
drawn  up  ;  turning  on  the  left  side  increases  the  amount  of  pain 
considerably.  The  breathing  will  often  be  shallow,  on  account 
of  the  pain  felt  in  prolonged  inspiration.  The  presence  or  absence 
of  jaundice  should  be  noticed. 

Palpation. — The  large  size  of  the  left  lobe  of  the  liver  may 
sometimes  be  mistaken  for  a  tumor,  either  on  the  surface  of  the 
liver  or  in  the  abdominal  cavity.  The  latter  may  be  diagnosti- 
cated by  the  fact  that  the  liver  will  move  during  respiration, 
whereas  a  tumor  would  remain  stationary.  The  normal  outline 
and  consistence  of  the  liver  may  be  changed  in  various  forms  of 
disease  affecting  it ;  thus,  in  amyloid  disease  a  distinct  induration 
of  the  surface  and  edge  may  be  detected  by  palpation,  and  where 
fatty  infiltration  has  taken  place,  these  parts  will  be  found  to  be 
smooth  and  soft,  while  in  cirrhosis  they  are  sharp  and  hard.  A 
characteristic  fremitus  will  very  often  be  detected  in  hydatid  dis- 
ease, and  a  friction  sound  in  perihepatitis.  In  palpating  and  in 
percussing  the  lower  borders  of  the  liver  care  should  be  taken  to 
empty  the  transverse  colon  thoroughly  previous  to  examination, 
as  a  quantity  of  feces  contained  in  this  part  of  the  bowel  will 
seriously  interfere  with  the  examination. 

Percussion. — In  the  practice  of  this  method  of  diagnosis  it 
should  be  remembered  that  in  order  to  outline  the  upper  borders 
of  the  liver  deep  percussion  must  be  employed,  while  it  is  best  to 
use  light  percussion  in  defining  the  lower  border.  By  means  of 
percussion  variations  in  the  size  of  the  liver  may  be  detected. 
An  irregular  enlargement  of  the  organ  may  point  to  a  hepatic 
abscess  or  hydatid  disease.  In  both  of  these  the  increase  in  dull- 
ness is  over  the  convexity,  if  this  part  of  the  organ  is  affected, 
the  area  running  upward  and  to  the  right ;  when  the  center  of 
the  organ  is  affected,  the  line  of  dullness  is  downward.  When 
the  left  lobe  is  enlarged,  an  increase  in  size  of  this  portion  can  be 
quite  distinctly  outlined.  When  fluid  is  present,  the  area  of  dull- 


JAUNDICE   OCCURRING    DURING    CHILDHOOD.  267 

ness  may  be  made  to  change  by  turning  the  patient  on  the  left 
side.  A  tumor  of  the  right  kidney  may  in  some  cases  give  the 
sensation  of  being  attached  to  the  liver  or  may  simulate  enlarge- 
ment of  that  organ,  but  a  line  of  tympanites  or  a  lighter  note  will 
be  detected,  and  the  finger  will  slip  between  the  lower  borders  of 
the  liver  and  the  tumor ;  when  doubt  as  to  the  diagnosis  exists, 
the  history  of  the  patient  and  an  examination  of  the  urine  will 
generally  settle  the  question.  Exploration  of  the  liver  can  also 
be  aided  by  aspiration  with  a  hypodermic  syringe.  By  this  method 
specimens  of  pus,  serum,  or  hydatid  fluid  may  be  drawn  off  and 
examined.  Pus  from  an  abscess  in  the  liver  will  contain,  prin- 
cipally, leucin  and  tyrosin,  and  possibly  the  characteristic  liver- 
cells.  When  the  fluid  is  reddish  brown  and  mixed  with  blood, 
and  especially  when  the  amcebae  dysenteriae  are  found  in  it,  the 
abscess  is  secondary  to  dysentery.  When  serum  is  drawn  by  the 
hypodermic  needle,  we  may  conclude  that  it  comes  from  the 
pleural  cavity  and  not  from  the  liver,  as  the  latter  does  not  yield 
serous  fluid.  The  fluid  from  a  hydatid  is  of  low  specific  gravity, 
alkaline  in  reaction,  and  clear.  It  contains  small  quantities  of 
albumin,  sugar,  and  a  considerable  amount  of  sodium  chlorid. 
Succinic  acid  may  also  be  found.  The  echinococcus-membrane, 
hooklets,  and  other  traces  of  the  parasitic  cause  of  the  disease 
will  be  found  on  microscopic  examination. 


JAUNDICE  OCCURRING  DURING  CHILDHOOD. 

Jaundice  may  occur  at  any  time  in  childhood,  although  the 
period  immediately  following  birth  is  the  one  in  which  it  is  most 
frequently  seen.  The  symptoms  are  usually  of  gradual  onset, 
being  those  of  a  more  or  less  severe  gastric  or  intestinal  catarrh, 
either  of  acute  or  subacute  origin.  The  liver  is  found  to  be  en- 
larged upon  percussion,  its  outline  extending  below  the  normal 
line  for  an  inch  or  two.  There  is  generally,  also,  some  tender- 
ness in  the  epigastrium  and  right  hypochondriac  region.  With 
these  symptoms  there  is  also  the  typical  coloring  of  the  skin, 
which  may  vary  from  a  yellow  to  a  brownish-yellow  or  almost 
greenish  tint.  The  ocular  conjunctiva,  and  even  the  mucous 
membranes  of  the  body,  may  share  in  the  general  discoloration. 
Occasionally  a  slight  rise  of  temperature  accompanies  these  symp- 
toms. An  itching  of  the  skin,  which  may  be  quite  distressing, 
is  frequently  felt. 

The  cause  is  generally  improper  feeding,  excesses  in  diet,  or 
taking  cold.  The  diagnosis  is  easy ;  the  discoloration  of  the 
skin,  the  slight  pyrexia,  the  history  of  indiscretions  in  diet  or 


268  DISEASES    OF    THE    LIVER. 

chilling  of  the  extremities  should  materially  aid  in  distinguishing 
the  condition.     The  prognosis  is  good. 

Treatment. — Jf  the  attack  of  jaundice  is  severe,  particularly 
if  fever  accompanies  it,  the  patient  should  be  kept  in  bed  for  a 
few  days.  Mild  counterirritation  may  be  made  over  the  epigas- 
trium by  rubbing  the  parts  with  some  stimulating  liniment  or  by 
the  application  of  a  mustard  or  spice  bath.  Massage  is  of  con- 
siderable use,  particularly  where  manipulations  can  be  made  over 
the  gall-bladder.  Faradic  electricity  has  also  been  advised.  The 
diet  is  a  matter  of  very  great  importance.  No  foods  containing 
starch  or  sugar  should  be  employed  ;  the  patient  should  be  kept 
upon  a  diet  of  milk,  diluted  and  made  alkaline  by  lime-water  or 
some  alkaline  mineral  water.  Musser  advises  that  this  milk  be 
taken  hot.  Animal  broths,  particularly  mutton  broth,  thin  chicken 
broth,  or  beef-tea,  should  be  the  principal  food  employed.  Foods 
containing  fat  should  not  be  given  the  patient.  When  the  diges- 
tion is  weak,  particularly  if  the  patient  is  inclined  to  vomit,  oyster 
or  clam  broth  or  koumiss  may  be  used  with  advantage.  As  the 
patient  improves  he  may  be  given  small  quantities  of  fresh  fish  or 
eggs  and  the  white  meat  of  chicken.  The  medicinal  treatment 
is  of  considerable  importance  in  jaundice.  If  seen  early,  very 
frequently  a  brisk  laxative  of  calomel,  combined  with  phosphate 
of  soda,  may  be  given  two  or  three  times  in  the  twenty-four 
hours,  this  being  followed  by  a  moderate  dose,  say  a  dram,  of 
castor  oil.  The  combination  of  calomel  and  bismuth  has  also 
been  found  to  be  of  use.  The  following  formula  has  been  recom- 
mended by  Musser  : 

R.     Liquor  potassii  citratis, f^ij 

Tinct.  opii  camph., f^j. 

SlG. — One-half  to  one  teaspoonful  every  two  or  three  hours. 

This  formula  is  particularly  useful  when  there  is  considerable 
pain.  When  vomiting  is  the  prominent  symptom,  minute  doses 
of  hydrochlorate  of  cocain  are  of  value.  The  treatment  of  the 
intestinal  catarrh,  from  which  this  condition  frequently  arises,  has 
already  been  dealt  with  at  length  and  will  not  be  repeated  ;  never- 
theless, there  are  a  few  special  symptoms  the  treatment  of  which 
should  require  attention.  Among  the  most  prominent  of  these 
may  be  mentioned  flatulence,  with  painful  digestion.  In  the  treat- 
ment of  this  condition  the  diet  should  be  such  as  will  be  quickly 
assimilated,  with  the  formation  of  as  little  gas  as  possible*  For 
the  medicinal  treatment,  extract  of  pancreatin  in  combination 
with  an  alkali,  given  an  hour  or  so  after  meals,  is  the  most  valu- 
able agent.  Naphthalene,  salol,  thymol,  creasote,  and  particularly 


JAUNDICE    OCCURRING    DURING    CHILDHOOD.  269 

charcoal,  may  all  be  used  with  good  effect  in  certain  cases.  As 
a  combination  of  the  two  last-named  agents,  Musser  recommends 
the  following  : 

K  •     Creosotum, gr-  X 

Carbo  lig. , gr.  j 

Pancreatin, gr.  j 

Bismuth,  subnitras, gr.  iij. 

SlG. — Ft.  chart  No.  i.     Take  after  meals. 

To  relieve  the  distressing  itching  of  the  skin,  which  is  some- 
times so  severe  as  to  cause  almost  continual  scratching,  a  spong- 
ing of  the  surface  with  ten  drops  of  carbolic  acid  to  a  pint  of 
water,  or  with  a  hot  solution  of  borax  or  bicarbonate  of  soda, 
will  be  found  very  useful.  If  this  fails,  Goodhart  recommends 
that  from  -^  to  -^  of  a  grain  of  pilocarpin  should  be  injected 
hypodermically.  For  the  cerebral  symptoms,  in  severe  cases, 
effort  should  be  made  to  hasten  as  much  as  possible  the  elimina- 
tion of  bile,  at  the  same  time  using  all  means  possible  to  support 
the  patient.  For  this  purpose  the  salts  of  ammonia,  particularly 
the  chlorid,  should  be  given  in  doses  of  from  one  to  five  grains, 
and  administered  in  the  syrup  of  orange  or  syrup  of  licorice,  or, 
better,  a  little  glycerin.  Phosphate  of  soda  is  also  probably  one 
of  the  most  valuable  drugs  that  can  be  employed  to  hasten  the 
elimination  of  bile.  Caffein  has  also  been  extensively  used,  and 
pilocarpin  is  a  valuable  agent  in  aiding  diaphoresis.  When  the 
temperature  becomes  subnormal,  and  especially  if  this  is  accom- 
panied by  considerable  prostration,  the  patient  should  be  fed  on  a 
nutritious,  highly  concentrated  diet  of  proteid  foods,  and  stimu- 
lation aided  by  moderate  doses  of  alcohol.  When  hemorrhages 
occur,  sulphuric  acid  and  the  acetate  of  lead  are  useful  as  astrin- 
gents. Turpentine  and  ergot  have  also  been  employed  for  this 
purpose.  When  the  blood  is  more  than  usually  depleted  by  the 
disease,  the  use  of  oxygen  has  been  recommended.  As  the 
patient  improves  he  may  gradually  return  to  a  more  varied  diet, 
although  for  a  long  time  fatty,  saccharine,  or  starchy  foods  must 
be  used  with  great  caution.  As  an  aid  to  digestion  and  also  to 
stimulate  hepatic  action,  probably  one  of  the  most  useful  medic- 
inal agents  is  hydrochloric  or  nitrohydrochloric  acid.  These 
may  be  given  internally  in  doses  of  one  or  two  drops,  combined 
with  some  bitter  tonic.  Local  applications  of  the  diluted  acid, 
applied  in  the  form  of  a  wet-pack  over  the  hepatic  region,  have 
been  used  with  very  good  results.  Another  method  which  has 
been  recommended  by  Musser,  and  which  was  invented  by  Krull, 
is  the  injection  of  from  two  to  four  pints  of  water  into  the  colon 
three  times  a  day.  The  temperature  of  the  water  is  raised  with 


2/O  DISEASES    OF    THE    LIVER. 

each  injection  ;  at  the  first  a  temperature  of  59°  F.  (15°  C.)  is 
used,  and  the  other  two  enemata  are  made  warmer  until  a  tem- 
perature of  72°  F.  (22.2°  C.)  is  reached. 


CONGESTION  OF  THE  LIVER. 

Two  forms  of  hepatic  congestion  are  described — namely,  the 
active  and  passive.  The  former  is  produced  by  an  exaggeration 
of  the  normal  congestion  of  the  organ,  which  is  produced  by 
the  stimulus  of  food.  The  causes  of  this  increase  in  blood 
supply  are  generally  overeating,  the  food  being  either  too  rich 
in  quality  or  of  a  too  great  quantity  ;  an  abuse  of  stimulants 
may  also  produce  the  condition,  but  this  is  rare  in  childhood. 

Symptoms. — Some  pain  is  experienced  in  the  region  of  the 
liver,  and  the  organ  will  be  found  to  be  enlarged  and  tender  on 
palpation.  The  increase  in  size  will  be  uniform,  sometimes  ex- 
tending for  a  distance  of  one  or  two  inches  beyond  its  normal 
boundaries.  The  edges  and  surfaces  are  smooth,  no  nodules 
being  felt.  When  the  gall-bladder  is  enlarged,  it  is  possible  to 
outline  it  in  the  right  hypochondriac  region  to  the  left  of  the 
midclavicular  line,  in  a  line  drawn  from  the  acromion  pro- 
cess of  the  right  scapula  to  the  umbilicus  (Musser).  The 
amount  of  jaundice  is  usually  slight.  The  passive  form  of  con- 
gestion in  almost  every  case  occurs  as  a  secondary  consequence 
to  diseases  of  the  heart  or  lungs.  The  liver  becomes  engorged 
with  blood,  this  condition  being  due  to  the  deficient  action  of 
the  lungs  or  heart.  Chronic  malarial  poisoning  is  also  given  as 
a  cause.  The  increase  in  size  is  slow,  constant,  and  uniform. 
According  to  Musser,  the  edge  of  the  liver  is  sharper  than  in  the 
active  variety  of  congestion  and  is  more  indurated.  "  In  the 
right  midclavicular  line  the  lower  border  may  extend  to  the  level 
of  the  umbilicus,  and  in  the  median  line  the  left  lobe  may  extend 
for  three-fourths  of  that  distance."  Where  there  is  effusion  in 
the  right  pleura,  the  upper  border  can  not  so  easily  be  made 
out.  The  constitutional  symptoms  are  those  of  gastro-intestinal 
catarrh  :  there  is  loss  of  appetite,  some  nausea  and  vomiting, 
constipation,  and  intestinal  dyspepsia.  'The  tongue  is  covered 
with  a  brownish  coat ;  the  amount  of  jaundice  is  usually  slight. 
In  the  passive  form  we  have,  in  addition,  the  constitutional 
symptoms  of  organic  diseases  of  the  heart,  lungs,  or  kidneys, 
affections  of  these  organs  being  the  most  frequent  cause  of  pass- 
ive congestion  of  the  liver.  The  urine  is  apt  to  be  albuminous 
and  contains  considerable  quantities  of  bile  pigments.  A  mod- 


PHYSICAL    SIGNS    OF    ACUTE    HEPATIC    ABSCESS.  2/1 

erate  amount  of  mental  depression  very  frequently  accompanies 
the  disease. 

The  prognosis  of  the  acute  form  of  congestion  is  favorable. 
In  the  passive  variety  the  prognosis  will  be  influenced  by  the 
extent  and  progress  of  the  disease  causing  the  congestion. 

Treatment. — The  main  objects  to  be  accomplished  in  treat- 
ment are  the  removal  of  the  cause  of  the  congestion  and  the 
relief  of  the  engorged  liver  by  the  judicious  use  of  purgatives. 
The  patient  should  be  put  on  a  low  diet,  and  all  starchy,  sac- 
charine, and  fatty  foods  excluded.  The  diet  should  consist  of 
animal  broths,  or  small  quantities  of  meat  and  such  other  foods 
as  are  digested  chiefly  in  the  stomach.  Purgatives  are  of  great 
use,  particularly  those  which  act  directly  on  the  liver.  The  two 
most  useful  of  this  class  of  agents  are  calomel  and  phosphate  of 
soda.  These  may  be  given  either  alone  or  in  combination. 
When  combined,  they  are  best  administered  in  the  form  of  a 
powder,  capsule,  or  combined  with  the  mistura  glycyrrhiza. 
Phosphate  of  soda  is  best  administered  at  bedtime  or  in  the 
morning.  It  may  be  given  in  hot  water,  soup,  or  broth.  Chlorid 
of  ammonia,  in  doses  of  from  three  to  five  grains  every  two  or 
three  hours,  has  been  greatly  praised.  Ipecacuanha  has  also 
been  used  with  great  benefit.  It,  however,  sometimes  produces 
such  an  amount  of  nausea  and  depression  as  to  reduce  its  favor- 
able action.  According  to  some  authorities,  it  should  be  admin- 
istered in  doses  as  large  as  five  grains,  twice  in  the  twenty-four 
hours,  to  children  under  five  years  of  age.  A  few  drops  of 
deodorized  tincture  of  opium  or  a  sinapism  over  the  epigastrium 
are  used  to  prevent  the  intense  nausea.  After  the  acute  symp- 
toms have  subsided,  dilute  nitric  acid  or  nitrohydrochloric  acid 
may  be  given  in  doses  of  from  two  to  ten  drops  three  or  four 
times  a  day,  or  local  applications  in  the  form  of  packs,  consist- 
ing of  cloths  wet  with  diluted  nitric  acid,  may  be  applied  over 
the  region  of  the  liver.  The  dyspeptic  symptoms  should  be 
treated  by  the  use  of  bitter  tonics  and  continued  small  doses  of 
calomel,  bismuth,  or  phosphate  of  soda.  Small  doses  of  silver 
nitrate  may  also  be  used  with  benefit.  The  passive  form  is  best 
relieved  by  treating  the  condition  causing  it. 

PHYSICAL  SIGNS  OF  ACUTE  HEPATIC  ABSCESS. 

The  liver  is  irregularly  enlarged,  the  increase  in  size  being 
sometimes  in  an  upwrard  direction  only  ;  generally,  however,  the 
lower  border  of  the  viscus  is  extended  downward.  Some  promi- 
nence of  the  diseased  lobe  may  be  felt  in  the  right  hypochondriac 


2/2  DISEASES    OF    THE    LIVER. 

or  epigastric  region.     Pain  will  be  experienced  on  palpation  over 
the  affected  area. 


MULTIPLE  HEPATIC  ABSCESS. 

The  symptoms  of  this  form  of  hepatic  inflammation  are  fre- 
quently only  those  of  the  disease  causing  it.  The  condition,  as 
has  been  before  stated,  arises  usually  from  infection  somewhere 
in  the  portal  area  ;  thus,  injuries  or  disease  of  other  abdominal 
viscera  will  produce  it.  Appendicitis  is  a  very  frequent  cause. 
Usually  the  symptoms  of  multiple  abscess  of  the  liver  are  pre- 
ceded by  indications  of  disease  in  some  other  abdominal  organ. 
The  special  symptoms  of  abscess  are  :  Jaundice  suddenly  appears, 
or,  where  this  is  not  very  marked,  the  skin  assumes  an  unhealthy, 
sallow  hue.  The  liver  becomes  enlarged  and  painful,  this  pain 
being  of  a  heavy,  dragging  character.  Fever  of  an  intermittent 
type  is  present,  and  there  are  daily  rigors.  In  some  cases  the 
fever  somewhat  resembles  typhoid.  The  tongue  becomes  dry 
and  covered  with  a  brownish  coat.  There  are  sordes  on  the 
teeth  and  lips.  Nausea  and  vomiting  are  present  and  are  accom- 
panied by  diarrhea,  the  stools  being  light  colored  aad  offensive. 
The  urine  rapidly  diminishes  in  quantity,  is  highly  colored,  and 
contains  much  bile  pigment.  Albumin  is  present.  A  micro- 
scopic examination  of  the  urine  will  demonstrate  the  presence  of 
blood  and  granular  and  epithelial  casts.  The  nervous  system 
soon  becomes  involved,  delirium  of  a  low,  muttering  type  appear- 
ing. Subsultus  is  present.  Later  the  patient  may  have  convul- 
sions or  may  pass  into  a  state  of  coma.  Death  may  occur  from 
exhaustion,  or  in  some  cases  the  kidneys  become  so  involved 
that  nephritis  may  produce  a  fatal  termination. 

Diagnosis. — In  acute  single  hepatic  abscess  resulting  from 
traumatism  the  diagnosis  can  be  made  by  the  history  of  injury, 
the  irregular  enlargement  of  the  liver,  and  the  symptoms  pointing 
to  suppuration.  In  doubtful  cases  the  exploratory  needle  may 
be  inserted,  under  strict  antiseptic  precaution,  to  aid  in  the 
diagnosis. 

When  multiple  abscesses  exist,  the  symptoms  of  hepatic  ab- 
scess following  evidences  of  disease  in  some  other  abdominal 
viscus  should  lead  us  to  suspect  the  presence  of  this  form  of 
hepatic  inflammation. 

Prognosis. — When  the  abscess  is  single  and  can  be  opened 
externally,  a  favorable  termination  of  the  case  is  possible.  The 
prognosis  of  multiple  abscess  is  very  grave. 

Treatment. — The  treatment  should  be  by  surgical  methods. 


SUPPURATIVE    INFLAMMATION    OF    THE    LIVER.  2/3 

According  to  the  best  authorities,  where  the  number  of  abscesses 
does  not  exceed  three,  free  incision  should  be  made.  When  the 
abscess  is  situated  along  the  margin  of  the  ribs  or  is  in  the  epi- 
gastric region,  the  operation  is  simple.  When  situated  in  the 
convexity  of  the  right  lobe,  Musser  advises  that  it  should  be 
opened  through  the  pleural  cavity,  and  in  this  case  excision  of 
the  ribs  is  necessary.  The  abscess  cavity  should  be  drained  and 
irrigated,  and  a  drainage-tube  inserted. 


SYPHILITIC  INFLAMMATION  OF  THE  LIVER. 

The  liver  may  undergo  changes  due  to  the  effect  of  general 
syphilitic  infection.  Two  forms  are  generally  seen.  In  one  the 
inflammation  is  chiefly  confined  to  the  capsule  of  the  organ,  and 
in  the  second  the  connective  tissue  of  Glisson's  capsule  is  the 
seat  of  the  organic  change.  The  liver  may  be  large  and  painful, 
or,  where  shrinking  of  the  connective  tissue  occurs,  the  organ 
may  diminish  in  size. 

Symptoms. — Other  manifestations  of  syphilis,  such  as  coryza, 
cutaneous  eruptions,  inflammation  of  the  mucous  membranes,  the 
peculiar  cranial  formation,  and,  in  fact,  any  of  the  sequence  of 
symptoms  of  specific  disease,  will  be  present.  There  may  be 
some  fever,  the  temperature  rising  to  100°  or  101°  F.  (37.7°  or 
38.3°  C.),  accompanied  by  a  corresponding  rise  in  the  pulse- 
rate.  There  may  be  pain  on  respiration.  Marked  tenderness 
will  be  found  on  palpation  and  percussion  over  the  liver.  A 
moderate  amount  of  jaundice  is  generally  seen.  When  contrac- 
tion is  occurring,  the  list  of  symptoms  will  embrace  in  addition 
those  of  portal  obstruction. 

Diagnosis. — This  will  be  made  from  the  direct  association  of 
the  changes  in  the  liver  with  other  symptoms  of  syphilis. 

The  treatment  is  that  of  general  syphilis. 


SUPPURATIVE  INFLAMMATION  OF  THE  LIVER. 
Synonym. — SUPPURATIVE  HEPATITIS. 

The  suppuration  may  arise  from  one  or  more  abscesses.  The 
most  frequent  cause  is  a  blow  or  fall  whereby  the  liver  is  injured. 
When  arising  from  this  source,  the  abscess  is  usually  single. 
Multiple  hepatic  abscesses  most  commonly  arise  from  infection  or 
suppuration  in  the  portal  system. 

Symptoms. — These  may  differ  widely  in  the  two  forms.  In 
the  traumatic  form  there  is  a  very  considerable  amount  of  pain 
18 


2/4  DISEASES    OF   THE    LIVER. 

in  the  hepatic  region,  accompanied  by  symptoms  of  perihepatitis. 
The  parts  about  the  seat  of  injury  are  swollen  and  discolored, 
and  general  evidences  of  traumatism  will  frequently  be  seen. 
The  symptoms  pointing  to  suppuration  may  follow  almost  imme- 
diately after  those  due  to  direct  injuries,  or  in  some  cases  they 
will  appear  several  days  after  the  entire  subsidence  of  all  external 
evidences  of  the  injury.  The  symptoms  of  the  formation  of  an 
abscess  are  pain  over  the  liver,  this  being  a  prominent  symptom 
and  generally  a  severe  one  ;  irregular  enlargement  of  the  viscus  ; 
fever,  either  of  a  remittent  or  intermittent  type.  The  rise  of 
temperature  is  preceded  or  followed  by  rigors  and  exhaustive 
sweats,  the  patient  rapidly  loses  flesh,  the  appetite  fails,  nausea 
and  vomiting  are  present,  and  in  many  cases  diarrhea  soon 
makes  its  appearance.  Respiration  becomes  difficult  and  painful, 
both  inspiration  and  expiration  being  affected.  The  pain  is 
generally  greatest  in  the  sixth  or  seventh  right  interspace  in 
front,  or  in  the  seventh  or  eighth  interspace  behind,  where  the 
seat  of  the  inflammation  is  on  the  convex  surface  of  the  liver. 


INTERSTITIAL  HEPATITIS. 

Synonyms. — CIRRHOSIS    OF  THE   LIVER  ;    HOBNAIL-LIVER  ;    GIN- 
DRINKER'S   LIVER  ;    SCLEROSIS    OF  THE  LIVER. 

Interstitial  hepatitis  is  an  inflammation  of  the  true  connective 
tissue  of  the  liver,  this  being  followed  by  contraction  and  hard- 
ening of  the  organ  and  an  atrophy  of  its  secreting  cells.  The 
principal  characteristics  of  the  condition  are  gastro-intestinal 
catarrh,  slight  jaundice,  ascites,  and  gradual  loss  of  bodily 
weight  and  general  health.  Interstitial  hepatitis  exists  in  infancy 
and  childhood  in  two  forms,  the  atrophic  and  the  hypertrophic. 
The  former  is  the  more  common,  the  latter  being  extremely  rare. 

Causes. — The  most  common  causes  are  syphilis  or  alcohol- 
ism, the  latter  in  childhood  being  most  frequently  produced  by 
the  too  constant  administration  of  alcohol  for  any  purpose 
during  the  early  period  of  life.  Chronic  heart  disease,  infectious 
fevers,  tuberculosis,  and  rachitis  may  all  be  etiologic  factors. 
Ptomainic  and  other  poisons  arising  from  imperfect  digestion 
may  produce  the  condition.  Atrophic  cirrhosis  is  the  most 
common  form  in  childhood,  the  hypertrophic  form  being  rarely 
seen  except  congenitally.  Interstitial  hepatitis  is  said  to  occur 
more  frequently  in  males  than  in  females,  and  although  it  may 
appear  at  any  period  of  childhood,  the  largest  number  of  cases 
occur  from  the  ninth  to  the  nineteenth  year. 


INTERSTITIAL    HEPATITIS.  2/5 

Symptoms. — In  the  beginning  the  symptoms  are  very  apt  to 
be  confounded  with  those  of  ordinary  hepatic  congestion  arising 
from  disturbances  of  the  digestive  tract.  There  are  nausea  and 
vomiting  or  attempts  to  vomit,  these  occurring  particularly  in 
the  morning.  The  vomited  matter  consists  largely  of  mucus. 
The  bowels  are  irregular,  being  sometimes  constipated,  while 
at  others  attacks  of  diarrhea  may  occur.  The  stools  contain 
considerable  mucus.  Hemorrhages  may  take  place  from  the 
nose,  mouth,  esophagus,  stomach,  or  intestines,  and  purpuric 
spots  are  occasionally  seen  in  different  parts  of  the  body.  Dila- 
tation of  the  subcutaneous  abdominal  veins  very  frequently 
occurs.  The  face  is  pale  or  of  a  sallow  hue,  and  numerous 
stigmata,  composed  of  groups  of  minute  veins,  are  seen  upon  it. 
There  is  a  slight  amount  of  jaundice.  This  may  be  constant, 
although  the  attacks  are  very  apt  to  recur.  A  moderate  amount 
of  ascites  is  almost  invariably  seen,  and  not  infrequently  this 
may  be  one  of  the  prominent  symptoms  of  the  disease.  From 
obstruction  to  the  portal  system  there  is  dilatation  of  the  veins, 
large  and  small,  particularly  the  superficial  veins  of  the  thorax 
or  abdomen.  Not  infrequently  a  well-defined  arch  is  seen  ex- 
tending across  the  chest,  marking  the  attachment  of  the  dia- 
phragm. The  superficial  abdominal  veins  are  also  in  many  cases 
fairly  outlined.  Enlargement  of  the  spleen  frequently  occurs. 
The  temperature  in  the  early  stages  is  moderately  elevated,  a 
rise  of  two  or  three  degrees  being  usual — 101°  to  102°  F.  (38.3° 
to  38.9°  C.).  This  is  most  commonly  observed  in  the  evening. 
As  the  disease  progresses,  however,  a  subnormal  temperature  is 
the  most  common.  The  urine  is  of  high  specific  gravity  and 
contains  large  quantities  of  uric  acid  and  urates.  If  nephritis 
develops,  which  it  very  frequently  does  during  the  course  of  the 
disease,  the  urine  will  become  albuminous  and  will  be  found,  on 
microscopic  examination,  to  contain  granular  and  hyaline  casts. 
Traces  of  sugar  will  sometimes  be  seen.  During  the  first  stage 
the  liver  enlarges,  but  later  steadily  diminishes  in  size,  this 
decrease  being  particularly  noticeable  in  the  left  lobe.  While 
dropsy  usually  seen  in  this  disease  is  abdominal,  yet  in  a  certain 
number  of  cases  swelling  of  the  lower  extremities  may  take 
place.  In  the  late  stages  of  the  disease  the  mind  becomes 
clouded,  largely  from  retention  of  the  various  products  of  ex- 
cretion, the  patient  becoming  first  dull,  and  later  passing  into 
coma  or  active  delirium.  Convulsions  may  occur. 

Pathology. — In  \h&  first  stage  there  is  hyperemia  of  the  con- 
nective tissue  of  the  liver,  followed  by  the  development  of  the 
connective-tissue  elements,  causing  an  increase  in  size  and  density 


2/6  DISEASES    OF    THE    LIVER. 

of  the  organ.  From  this  hypertrophy  of  the  connective  tissue 
pressure  is  made  upon  the  true  hepatic  cells,  causing  them  to 
undergo  fatty  degeneration.  In  the  second  stage  the  imperfectly 
developed  connective  tissue  contracts,  causing  the  organ  to  de- 
crease in  size,  and  producing  induration.  Its  surfaces  become 
nodulated,  thus  giving  the  liver  the  appearance  which  is  usually 
characterized  by  the  term  "hobnail."  Obstruction  to  the  portal 
and  hepatic  circulations  soon  occurs. 

The  diagnosis  is  to  be  based  upon  the  physical  signs,  the 
symptoms  of  portal  obstruction,  and  the  characteristic  appear- 
ance of  the  face.  The  diseases  with  which  cirrhosis  is  most 
likely  to  be  confounded  are,  first,  atrophy  of  the  liver ;  but  cir- 
rhosis most  commonly  follows  obstructive  diseases  of  the  heart 
or  lungs.  In  atrophy  no  nodulation  of  the  organ  occurs,  and 
the  history  of  alcoholism  or  syphilis  is  generally  wanting.  Sec- 
ond, cirrhosis  must  be  differentiated  from  tubercular  peritonitis  ; 
in  this  disease  the  abdominal  tenderness  is  general  ;  there  is 
rapidly  developing  ascites,  absence  of  jaundice,  and,  in  the 
majority  of  cases,  the  symptoms  of  gastro-intestinal  dyspepsia 
are  absent.  On  percussion  the  liver  will  be  found  to  be  normal. 
There  are  also,  as  a  general  rule,  evidences  of  tuberculosis  in 
other  organs  of  the  body.  Cancer  of  the  peritoneum  may  have 
some  symptoms  resembling  those  of  perihepatitis,  but  this  disease 
occurs  very  rarely  in  childhood.  The  liver  will  be  found  normal 
upon  examination,  and  there  will  be  other  symptoms  character- 
istic of  cancerous  disease. 

The  prognosis  is  very  unfavorable. 

Treatment. — The  indications  for  treatment  are,  first,  to  remove 
the  causes  ;  second,  to  prevent,  so  far  as  possible,  the  increase  of 
connective-tissue  growth,  and  to  relieve  the  engorgement  of  the 
hepatic  and  portal  circulation.  Third,  if  the  case  is  too  far 
advanced  for  cure,  we  must  then  endeavor  to  relieve  the  symp- 
toms as  they  arise.  In  order  to  meet  the  first  indication  the 
causes  of  irritation  must  be  removed.  The  patient  should  be 
allowed  no  alcohol  in  any  form  ;  all  highly  seasoned,  fatty,  or 
saccharine  foods  must  be  given  up,  and  even  articles  of  food  con- 
taining starch  must  be  used  with  great  caution.  The  diet  should 
consist  principally  of  the  lighter  meats,  such  as  the  white  meat 
of  chicken  or  turkey,  although  other  animal  diet  may  be  employed 
in  moderation.  To  better  insure  its  digestion  it  is  well  to  have 
the  meat  finely  chopped,  and  made  into  the  form  of  a  meat  ball, 
without  fat,  and  carefully  browned.  As  a  continuous  animal 
diet  may  tend  to  cause  scorbutus,  doses  of  lemon-juice  or 
diluted  citric  acid  must  be  administered  occasionally  to  counter- 


INTERSTITIAL    HEPATITIS. 

act  this  tendency.      Eggs  may  also  be  employed  as  an  article  of 
diet. 

Probably  the  best  food  for  these  cases  is  milk, — either  the  best 
dairy  milk,  skimmed,  or  buttermilk  may  be  used, — or  in  some 
cases  where  the  patient  tires  of  this  article  of  food,  which  is  gen- 
erally the  case  in  a  short  time,  it  may  be  administered  in  the  form 
of  various  desserts,  such  as  junket,  blanc  mange,  or  light  pud- 
dings. The  tendency  to  constipation  must  be  corrected  by  the 
administration  of  alkaline  aperient  waters,  such  as  Hunyadi,  Sara- 
toga, or  Carlsbad.  Vegetables  such  as  spinach,  lettuce,  or  those 
containing  little  or  no  starch  may  be  allowed,  but  potatoes,  rice, 
and  other  vegetables  containing  much  starch  should  be  used  spar- 
ingly, if  at  all.  The  question  of  dress  is  of  some  importance. 
The  patient  should  wear  flannel  next  to  the  skin  the  year  round, 
and  should  dress  warmly  enough  to  avoid  chilling.  An  outdoor 
life  in  the  open  air  is  best  for  these  cases.  The  medicinal  treat- 
ment should  be  directed  toward  the  relief  of  the  engorgement  and 
the  prevention  of  the  increase  of  the  pathologic  conditions  causing 
it.  The  application  of  cups  and  leeches,  which  has  been  practised 
by  some,  is  not  now  recommended  by  best  authorities,  although 
counterirritation  over  the  liver  by  the  use  of  some  stimulating 
liniment  may  probably  be  of  some  slight  use.  The  benefit  de- 
rived by  having  the  patient  drink  freely  of  hot  water,  say  a  glass- 
ful half  an  hour  before  eating,  each  draft  to  contain  from  two  to 
five  grains  of  sodium  phosphate,  is  very  considerable.  The  saline 
cathartics  or  laxative  mineral  waters  are  exceedingly  beneficial. 
The  patient  should  have  from  three  to  six  liquid  movements  a 
day.  To  prevent  the  increase  of  connective  tissue  in  the  organ 
many  drugs  have  been  recommended.  One  of  the  most  highly 
lauded  is  chlorid  of  ammonia.  This  should  be  given  in  doses  of 
from  two  to  five  grains  every  four  or  five  hours.  It  is  best  ad- 
ministered in  some  syrup  or  elixir.  Probably  one  of  the  most 
useful  agents  which  has  stood  the  test  of  time  is  phosphate  of 
soda ;  this  should  be  given  in  doses  of  from  five  to  ten  grains, 
according  to  the  age  of  the  child.  It  is  best  administered  in  hot 
water,  and  may  sometimes  be  disguised  in  soup,  being  used  in 
the  place  of  salt.  Potassium  iodid  is  said  to  retard  the  changes 
in  the  organ  when  given  in  the  early  stages.  In  cases  of  syph- 
ilitic origin  this  drug,  of  course,  will  have  a  particular  usefulness. 
Small  and  continued  doses  of  mercury,  in  the  form  of  calomel, 
bichlorid,  or  gray  powder,  are  valuable  agents.  In  advanced 
cases,  where  the  principal  indication  is  the  relief  of  the  various  dis- 
tressing symptoms  of  the  disease,  these  should  be  treated  as  they 
arise.  Where  ascites  is  marked,  the  patient  should  be  placed  on  a 


2/8  DISEASES    OF    THE    LIVER. 

dry  diet,  principally  of  meat.  The  gastro-intestinal  dyspepsia 
which  always  accompanies  the  malady  should  be  treated  as  in 
other  cases.  Hemorrhage  from  the  stomach  or  other  part  of  the 
digestive  tract  requires  rest  in  bed,  the  administration  of  cracked 
ice,  and  the  application  of  an  ice-bag  externally.  Where  the 
hemorrhage  is  of  gastric  origin,  food  should  be  administered  by 
rectum.  Opium  should  always  be  given  to  quiet  the  patient, 
and  may  be  used  in  either  the  form  of  morphin  hypodermically 
or  paregoric  in  suitable  doses,  administered  alone  or  in  combi- 
nation with  an  astringent,  such  as  sulphuric  acid.  The  following 
formula,  recommended  by  Musser,  is  useful  in  these  cases  : 

R.     Tinct.  opii  camph., 

Acid,  sulphuric,  aromat., aa    f  3;j. 

SlG. — Eight  to  ten  drops  in  water  every  two,  three,  or  four  hours. 

Various  astringents,  such  as  acetate  of  lead,  bismuth,  nitrate 
of  silver,  and  many  others,  have  been  employed.  Hamamelis, 
in  doses  of  twenty  drops  every  hour  or  two,  has  been  em- 
ployed with  benefit.  The  various  preparations  of  iron,  particu- 
larly Monsel's  salt,  given  in  the  form  of  a  hard  pill  of  one  grain, 
is  of  use  in  intestinal  hemorrhage.  In  cases  of  hemorrhage  from 
the  lower  bowel,  astringent  enemata  should  be  employed.  Ascites 
should  be  treated  by  the  administration  of  diuretics  and  saline 
cathartics.  Drafts  of  cream  of  tartar  dissolved  in  water  are  valu- 
able for  this  purpose,  and  are  rather  pleasant  to  the  patient.  In- 
fusion of  scoparius  has  also  given  good  results  in  these  cases,  but 
probably  the  best  of  all  drugs  for  this  purpose  is  calomel.  This 
may  be  used  alone,  or  in  combination  with  a  compound  jalap 
powder.  Copaiba  gives  a  more  permanent  result.  Where  the 
child  is  old  enough  to  take  the  drug  in  this  form,  it  may  be  admin- 
istered in  the  capsule  containing  three  minims,  to  be  taken  every 
four  hours.  Where  the  heart  is  weak,  caffein  or  digitalis  should 
be  employed,  and  hydrochlorate  of  cocain  is  also  said  to  have 
given  good  results  for  this  purpose.  As  in  the  late  stages  of 
the  disease  death  frequently  takes  place  from  exhaustion,  stimu- 
lants and  cardiac  tonics  should  be  used  where  this  condition  is 
threatened.  Paracentesis  may  be  employed  frequently.  The 
jaundice  requires  no  special  treatment. 

FATTY  LIVER. 

The  so-called  fatty  liver  consists  in  a  uniform  enlargement  of 
the  organ,  due  to  its  becoming  infiltrated  with  fatty  elements. 
As  a  rule,  there  is  no  actual  degeneration  of  the  true  hepatic 
structure.  It  is  an  intercurrent  affection,  being  associated  with 


AMYLOID    DISEASE    OF    THE    LIVER. 

gastro-intestinal  catarrh,  tuberculosis,  or  other  wasting  disease. 
The  excessive  use  of  saccharine  or  starchy  food,  particularly 
where  associated  with  a  sedentary  life  during  childhood,  is  also 
an  etiologic  factor. 

Symptoms. — There  is  a  uniform  enlargement  of  the  liver,  its 
surface  is  smooth,  and  palpation  causes  no  pain.  The  surfaces 
of  the  organ  are  smooth  and  soft,  and  its  edges  rounded.  The 
general  symptoms  are  negative. 

The  treatment  should  consist  in  strict  attention  to  the  hygiene 
and  diet.  Foods  containing  large  quantities  of  carbohydrates 
must  be  excluded.  The  patient  should  take  plenty  of  outdoor 
exercise,  or,  where  this  is  impossible,  should  receive  massage. 
A  large  part  of  the  treatment  consists  really  in  treating  the  dis- 
ease from  which  the  fatty  infiltration  arises. 


AMYLOID  DISEASE  OF  THE  LIVER. 

Synonyms. — LARDACEOUS     LIVER  ;    WAXY     LIVER  ;     SCROFULOUS 
LIVER  ;  ALBUMINOUS  LIVER. 

Amyloid  disease  consists  in  a  degeneration  of  the  liver  struc- 
ture, caused  by  deposits  of  an  albuminoid  material  the  micro- 
scopic appearance  of  which  resembles  starch  granules.  The  dis- 
ease may  appear  at  any  age  of  childhood,  and  in  the  majority  of 
cases  occurs  in  the  course  of  suppurative  diseases,  particularly 
those  of  a  chronic  nature,  such  as  tuberculosis,  especially  tuber- 
culous bone  affections,  syphilis,  and  rachitis.  It  is  frequently 
associated  with  amyloid  disease  in  other  organs. 

Pathology. — The  liver  presents  a  pale,  glistening,  anemic 
appearance  and  has  a  doughy  consistency.  There  is  a  uniform 
enlargement  of  the  organ.  There  are  certain  chemic  tests 
whereby  the  presence  of  amyloid  degeneration  can  be  easily  ascer- 
tained. One  of  these  is  made  by  first  cleansing  the  surface  of 
the  organ  and  then  brushing  over  it  an  aqueous  solution  of  iodin 
with  iodid  of  potassium.  Wherever  the  deposits  of  amyloid  sub- 
stance have  taken  place  these  will  assume  a  brownish  or  mahog- 
any color,  which  in  turn  will  change  to  violet  or  a  bluish  tint  if 
diluted  sulphuric  acid  is  added.  Another  test  consists  in  brush- 
ing the  liver  over  with  a  solution  of  anilin  violet  of  the  strength 
of  i  per  cent.  This  will  produce  a  red  or  pinkish  color  on  com- 
ing in  contact  with  the  amyloid  deposits,  the  unaltered  tissues 
being  stained  blue. 

Symptoms. — Anemia  is  usually  the  most  prominent  symptom. 
There  maybe  some  prominence  of  the  external  abdominal  veins. 


28O  DISEASES    OF   THE    LIVER. 

Where  jaundice  is  present  it  is  slight,  but  in  the  majority  of  cases 
it  does  not  appear.  Diarrhea  is  generally  a  prominent  symptom, 
and  hemorrhage  from  the  bowels  may  occur.  Dyspepsia  is  com- 
mon. Where  the  kidneys  share  in  the  amyloid  degeneration, 
dropsy  in  various  parts  of  the  body  may  occur.  In  these  cases 
the  urine  will  be  increased  in  amount  and  will  contain  albumin. 
Palpation  will  show  that  the  liver  is  greatly  increased  in  size, 
sometimes  attaining  two  or  three  times  its  normal  dimensions. 
This  enlargement  is  uniform.  The  edges  of  the  organ  will  be 
found  to  be  round  and  hard,  and  palpation,  as  a  rule,  does  not 
give  pain.  Enlargement  of  the  spleen  is  generally  a  coincident 
symptom. 

Diagnosis. — Amyloid  disease  may  be  suspected  in  any  case 
where  increase  in  the  size  of  the  abdomen  occurs  in  the  course 
of  a  chronic  suppurative  disease.  In  suspected  cases  examina- 
tion of  the  kidneys  and  spleen  should  be  made,  and  where  these 
are  found  to  share  in  the  amyloid  degeneration,  diagnosis  is  posi- 
tive. Intended  surgical  operations  on  the  bones  and  joints 
should  not  be  attempted  during  the  course  of  this  disease. 

The  prognosis  is  unfavorable  ;  although  the  affection  may 
proceed  either  rapidly  or  slowly,  the  termination  is  always  fatal. 

Treatment. — Outside  of  the  fact  that  all  effort  possible  should 
be  made  to  bring  the  patient's  system  into  as  good  a  condition 
as  possible  by  the  use  of  tonics  and  the  best  hygienic  surround- 
ings, the  treatment  is  largely  symptomatic.  Various  drugs  have 
been  recommended,  particularly  chlorid  of  ammonia  and  syrup 
of  the  iodid  of  iron.  lodin  has  also  its  advocates,  but  in  the 
majority  of  cases  dependence  upon  any  of  these  agents  will  be 
found  to  be  disappointing.  Efforts  should  be  made  to  remove 
the  cause  as  quickly  as  possible,  especially  where  this  arises  from 
any  suppurating  disease  of  the  bones.  In  cases  where  conges- 
tion of  the  hepatic  or  portal  circulations  due  to  cardiac  weakness 
occurs,  such  drugs  as  digitalis,  strophanthus,  or  other  heart  tonics 
will  be  found  of  service. 


ACUTE  YELLOW  ATROPHY  OF  THE   LIVER. 

Yellow  atrophy  is  very  rare  in  childhood.  At  this  period  of 
life  the  etiologic  factors  are  usually  syphilis  or  poisoning  from 
phosphorus.  The  disease  is  also  known  by  the  names  of  gen- 
eral parenchymatous  hepatitis  and  malignant  jaundice. 

Pathology. — At  first  there  is  hyperemia  of  the  hepatic  cells, 
with  a  grayish  exudation  between  the  lobules  ;  following  this  the 
cells  undergo  fatty  degeneration.  A  marked  reduction  in  the 


HYDATID    DISEASE.  28  I 

size  and  weight  of  the  organ  occurs.  The  spleen  is  enlarged,  and 
degeneration  of  the  kidneys  takes  place.  The  urine  contains  bile 
pigments  and  albumin,  and  generally  crystals  of  leucin  and  tyrosin 
will  also  be  found  in  it.  The  disease  is  of  insidious  onset ;  there 
are  symptoms  of  general  malaise,  accompanied  by  icterus.  In 
the  beginning  there  is  a  slight  elevation  of  temperature,  some 
pain  over  the  epigastrium,  headache,  nausea,  vomiting,  and  a 
coated  tongue.  As  the  disease  progresses  the  headache  becomes 
worse, — indeed,  is  generally  a  prominent  symptom, — the  pulse 
becomes  slow,  and  the  jaundice  intense.  Later,  the  patient 
shows  all  the  symptoms  of  profound  toxemia.  There  may  be 
fever,  or  occasionally  a  subnormal  temperature.  The  stools  are 
black  and  tarry,  and  vomiting  of  black,  grumous  substance,  the 
so-called  coffee-grounds  vomit,  may  occur.  In  the  last  stages 
the  patient  becomes  comatose  or  may  die  in  convulsions. 

The  treatment  is  chiefly  symptomatic  ;  efforts  should  be  made 
to  relieve  the  toxemia  by  hot  packs,  hot  drinks,  and  the  admin- 
istration of  calomel  or  other  agents  that  will  act  on  the  liver. 
Diuresis  should  be  encouraged.  Small  doses  of  phosphorus 
have  been  recommended,  but  have  so  far  proved  of  no  avail. 

HYDATID   DISEASE. 

Although  hydatid  disease  is  a  rare  affection,  it  is  occasionally 
seen  in  children.  The  methods  of  infection  are  the  same  as  in 
the  adult.  The  first  symptom  noticed  is  generally  enlargement 
of  the  abdomen,  the  tumor  being  greatest  in  size  in  the  region  of 
the  liver.  This  enlargement  of  the  hepatic  region  may  be  general, 
although  usually  the  greatest  amount  of  swelling  corresponds  to 
the  position  of  the  cyst.  If  this  is  situated  on  the  convex  side  of 
the  liver,  percussion  will  demonstrate  that  the  normal  area  of 
dullness  extends  higher  in  the  axillary  region  in  front  and  in  the 
scapular  regions  behind.  If  the  cyst  is  situated  in  the  right  lobe, 
dullness  will  be  found  to  extend  downward  toward  the  umbilicus, 
and  when  in  the  left  lobe,  examination  will  reveal  the  presence 
of  the  greatest  amount  of  swelling  in  the  epigastric  region.  The 
tumor  is  usually  painless,  and  percussion  over  it  will  cause  little 
or  no  discomfort.  Fluctuation  may  be  found,  and  occasionally 
the  symptom  known  as  hydatid  fremitus  may  be  detected  by 
placing  one  hand  over  the  tumor  and  forcibly  and  quickly  tapping 
another  part  of  the  tumor  with  the  other  hand.  There  is  gen- 
erally little  or  no  deterioration  in  the  general  health  so  long  as 
the  cyst  remains  unruptured  or  there  is  no  great  pressure  upon 
the  hepatic  duct.  Jaundice  is  either  slight  or,  where  it  does 


282  DISEASES    OF    THE    LIVER. 

appear,  it  develops  slowly.  Rupture  of  the  cyst  is  generally 
followed  by  symptoms  of  pyemia,  and  whenever  in  the  course  of 
development  of  a  hydatid  cyst  periodic  elevations  of  temperature 
arise,  these  being  preceded  by  rigors  and  followed  by  sweats  and 
general  prostration,  rupture  of  the  cyst  can  generally  be  diag- 
nosticated. This  rupture  may  take  place  into  the  hepatic  duct 
or,  in  some  cases,  into  the  surrounding  organs,  such  as  the  pleura, 
colon,  bronchi,  or  even  into  the  pericardium  or  vena  cava. 

The  diagnosis  is  principally  made  from  the  character  of  the 
enlargement  of  the  liver.  An  irregular  increase  in  size,  the  pres- 
ence of  fluctuation,  the  absence  of  pain  on  palpation,  and  the 
continuance  of  a  fairly  good  condition  of  general  health  serve  as 
diagnostic  points.  From  hepatic  syphilis  hydatid  disease  must 
be  distinguished  by  the  fact  that  in  the  former  the  enlargement, 
although  present,  is  irregular,  the  liver  is  harder,  and  some  of  the 
general  symptoms  of  specific  disease  will  be  present.  The  diag- 
nosis between  hydatid  cysts  and  abscess  of  the  liver  is  often  one 
of  extreme  difficulty.  In  abscess  there  is  usually  a  history  of 
traumatism  ;  there  are  pain  and  tenderness  over  the  liver,  and  the 
general  symptoms  are  more  rapid  in  their  onset.  Hydronephrosis 
may  in  some  cases  be  mistaken  for  hydatid  disea'se,  but  the 
former  is  very  rare  in  children.  When  doubt  exists,  an  explora- 
tory puncture  will  aid  in  diagnosis.  Affections  of  the  pleura  may 
be  in  some  cases  confounded  with  hydatid  disease,  and  the  diag- 
nosis may  be  rendered  particularly  difficult  where  a  cyst  has  rup- 
tured into  the  right  pleural  cavity.  In  the  latter  case  probably 
the  only  point  of  differentiation  will  be  the  presence  of  the  hook- 
lets  of  the  echinococcus  in  the  sputum. 

The  prognosis  is  variable.  A  fair  number  of  cases  will  prob- 
ably go  for  years  with  one  or  more  of  these  cysts  gradually 
developing  in  the  liver.  Indeed,  cases  have  been  reported  in 
which  spontaneous  cure  has  occurred.  When  the  cyst  is  in  such 
position  that  it  can  be  attacked  by  operative  measures,  its  removal 
is  recommended  by  most  authorities. 

Treatment. — It  is  generally  considered  that  the  best  results 
in  treatment  are  obtained  by  surgical  means.  The  abdomen 
should  be  opened  at  the  most  prominent  part  of  the  tumor,  and 
the  cyst  evacuated.  If  any  small  cysts  exist,  they  should  be 
carefully  emptied  at  the  same  time  and  a  thorough  irrigation  of 
the  abdominal  cavity  should  be  practised.  It  is  generally  rec- 
ommended that  the  drainage-tube  be  left  in  the  incision.  Great 
care  must  be  taken  to  remove  every  part  of  the  cyst,  as  suppura- 
tion will  take  place  if  any  portion  of  the  original  cyst  or  daughter 
cysts  is  allowed  to  remain.  Where  the  cyst  is  situated  in  the 


HYDATID    DISEASE.  283 

upper  surface  of  the  liver,  it  is  sometimes  necessary  to  open  it 
through  the  diaphragm  ;  in  this  case  one  or  two  ribs  must  be 
resected  and  the  pleura  stitched  to  the  diaphragm. 

Electricity  and  injections  into  the  cyst  have  been  tried,  but 
have  not  met  with  much  success.  In  cases  where,  for  any  rea- 
son, laparotomy  can  not  be  done,  it  has  been  advised  by  some 
that  the  cyst  be  opened  by  means  of  a  large  trocar  and  cannula, 
and  a  drainage-tube  inserted  through  the  latter.  Simon's  method 
consists  in  passing  needles  into  the  tumor,  so  as  to  cause  an 
adhesive  inflammation,  and  then  later  to  practise  incision.  Aspi- 
ration has  also  been  followed  by  temporary  success  and  has  been 
recommended  by  Dieulafoy  and  Murchison.  Even  after  opera- 
tive treatment  recurrence  may  take  place,  even  as  late  as  two  or 
three  years  after  incision,  as  in  two  cases  reported  by  Morris. 
Biliary  fistula  is  also  one  of  the  secondary  dangers  of  operative 
treatment,  and  cases  of  this  have  been  recorded. 


CHAPTER  VIII. 
DISEASES  OF  THE  GENITOURINARY  SYSTEM. 


THE  URINE. 

Before  the  time  at  which  a  child  may  have  acquired  regular 
habits  of  urination  the  most  practicable  way  to  procure  a  speci- 
men of  urine  for  examination  is  by  means  of  a  soft  catheter.  When 
this  is  undesirable  or  impossible,  the  child  may  be  placed  at 
short  intervals  upon  the  chamber,  and  hot  or  cold  applications 
made  over  the  bladder  or  sacrum  to  encourage  micturition. 

The  urine  may  sometimes  be  caught  in  small  quantities  in  a 
cloth  or  pledget  of  cotton  fastened  over  the  penis  or  vagina,  or, 
as  Holt  recommends,  a  small  condom  or  bottle  suspended  in 
such  a  way  that  the  penis  may  be  introduced  into  it. 

The  Quantity. — The  quantity,  as  in  adults,  varies  between 
wide  limits,  depending  upon  the  amount  and  quality  of  the  food 
ingested  and  according  as  a  small  or  a  large  quantity  of  water 
is  carried  off  by  way  of  the  skin  or  the  bowels. 

AVERAGE  QUANTITY  OF  URINE  PER  DIEM  IN 
CHILDHOOD.* 

First  24  hours, o 

Second  24  hours, 10 

3  to  6  days, 90 

7  days  to  2  months,  ....  150 

2  to  6  months, 210 

6-months  to  2  years,     .    .    .  250 

2  to  5  years, 5°° 

5  to  8  years, 600 

8  to  14  years, looo 

Up  to  about  the  third  year  a  healthy  infant  while  awake  passes 
its  urine  at  frequent  intervals,  often  every  half-hour  or  so,  but 
when  lying  quietly  and  asleep  may  retain  it  for  a  much  longer 
time — even  for  five  or  six  hours.  During  the  second  year  the 
child  retains  its  urine  an  hour  or  so  longer,  and  so,  as  its  age 

*  This  and  the  following  table  have  been  compiled  by  Emmet  Holt  from  statistics 
given  by  Schatanowa,  Cruse,  Camerer,  Pollak,  Martin-Ruge,  Berti,  Schiff,  and 
Herter. 

284 


o      60  grams  (  o  to 

2  ounces) 

90 

(#*> 

3  ounces) 

250 

(  3  to 

8  ounces) 

400 

(  5  to 

13  ounces) 

500 

(  7  to 

16  ounces) 

600 

(  8  to 

20  ounces) 

800 

(16  to 

26  ounces) 

1  200 

(20  to  40  ounces) 

1500 

(32  to 

48  ounces). 

THE    URINE.  285 

advances,  the  frequency  of  urination  gradually  diminishes  to  the 
average  of  adult  life. 

During  the  first  few  days  after  birth  the  urine  is  highly  colored, 
strongly  acid  in  reaction,  precipitating  in  comparatively  large 
quantity  uric  acid  and  urates  ;  later  it  becomes  paler,  of  lower 
specific  gravity,  but  still  may  be  cloudy  from  the  presence  of 
urates  and  mucus.  Hyaline  and  granular  casts  may  also  be 
found  in  the  new-born  (Martin-Ruge).  Virchow  was  the  first  to 
show  the  presence  of  albumin  also  at  this  period. 

AVERAGE  SPECIFIC  GRAVITY  OF  URINE  IN  CHILDHOOD. 


1  to  3  days, , i.oio  to 

4  to  I  o  days, 1.004  to 

IO  days  to  6  months, 1.004  to 

6  months  to  2  years, 1.006  to 

2  to  8  years, 1.008  to 

8  to  14  years, 1.012  to 


.012 
.008 
.010 
.012 
.016 
.020. 


The  phosphates,  chlorids,  and  sulphates  are  reduced  in  pro- 
portion, gradually  increasing  in  amount  with  the  age. 

AVERAGE  EXCRETION  OF  UREA  PER  DIEM  IN  CHILDHOOD. 

First  day,      0.07610    0.114  grams. 

2  to  7  days, 0. 14    "    0.66       " 

1  to  2  months, 0.9      "     1.4         " 

3  to  5  years, !3-°9     "  14.01       " 

5  to  13  years, 16.05     "  21.03       " 

RATIO  OF  UREA  TO  URIC  ACID. — (Herter.) 

New-born,* 14  to  I 

First  year, 60-80  "  i 

2  to  5  years, 5°~7o  "  I 

5  to  15  years, 45-6°  "  I. 


ANURIA. 

Definition. — Anuria  is  a  complete  cessation  of  the  secretion 
of  urine  by  the  kidneys. 

Causes. — In  rare  instances  it  may  be  the  result  of  congenital 
malformation  of  some  portion  of  the  urinary  tract.  It  may 
occur  in  the  course  of  fevers  or  acute  Bright's  disease,  but  here 
there  is  more  often  only  an  oliguria.  Some  of  the  commoner 
causes  are  hysteria,  shock  from  fright,  traumatism,  or  operations, 
after  the  passage  of  a  catheter  or  the  administration  of  ether  or 
chloroform,  certain  poisons,  such  as  arsenic,  turpentine,  lead,  and 
phosphorus.  In  collapse  during  typhoid  fever  there  may  be  no 

*  From  Martin-Ruge. 


286  DISEASES    OF    THE    GENITO-URINARY    SYSTEM. 

urine  secreted  for  some  time.  It  may  be  due  to  the  presence  of 
a  calculus  blocking  one  or  both  ureters. 

Prognosis. — It  will  often  be  seen  in  infants,  when,  after  a 
period  as  long  even  as  twenty  hours,  the  urine  will  again  make 
its  appearance  and  with  the  development  of  no  serious  symptoms. 

As  to  the  length  of  time  a  patient  may  live  with  absolute  sup- 
pression of  the  urine,  Herter  collected  a  series  of  cases  in  which 
recovery  occurred  after  periods  ranging  from  four  to  fourteen 
days,  and  Bailey  reports  an  instance  of  a  young  girl  where,  so 
far  as  the  author  could  tell,  urine  was  passed  but  once  from 
October  loth  to  March  ist.  Some  doubt,  however,  is  expressed 
as  to  the  truth  of  the  patient's  statements. 

Treatment. — When  the  cause  is  removable,  it  will  receive 
the  first  consideration,  and  the  treatment  of  the  condition  should 
be  the  application  of  cups  or  hot  fomentations  over  the  kidneys, 
free  administration  of  purgatives  and  diaphoretics,  followed  by 
diuretics.  Large  hot  irrigations  with  normal  salt  solution  should 
be  .tried,  as  they  stimulate  the  activity  of  the  kidney  in  a  remark- 
able way  (Osier). 

POLYURIA. 

Definition. — Polyuria  is  a  temporary  increase  in  the  secretion 
of  urine. 

Causes. — It  is  produced  by  drinking  large  quantities  of  water, 
by  hysteria  or  fright,  exposure  to  cold,  and  by  diuretics ;  it 
appears  in  certain  forms  of  Bright' s  disease  and  brain  lesions,  at 
times  in  convulsions  and  acute  febrile  diseases,  and  with  the 
resorption  of  large  serous  effusions. 

Diagnosis. — It  is  to  be  distinguished  from  diabetes  insipidus 
in  that  the  latter  shows  a  tendency  to  become  chronic  in  type, 
and  is  apt  to  be  associated  with  changes  that  are  organic  rather 
than  functional. 

PHYSIOLOGIC  GLYCOSURIA. 

Glucose  is  now  generally  considered  to  be  a  constituent  of 
normal  urine,  but  in  quantity  too  small  to  show  a  reaction  with 
the  older  tests,  such  as  Fehling's,  etc.,  but  responding  to  the 
phenylhydrazin  test.  This  is  of  no  clinical  significance,  and 
therefore  phenylhydrazin  is  inadvisable  for  ordinary  use.  It  oc- 
curs sometimes,  however,  in  the  urine  of  otherwise  healthy 
children,  probably  from  some  faulty  metabolism.  Sugar,  in  the 
form  of  lactose,  is  often  found  in  infancy  and  childhood,  and  is 
derived  from  the  milk. 


INDICANURIA.  28/ 


INDICANURIA. 

Indol  is  a  product  of  the  putrefaction  of  albumin  from  the 
action  of  bacteria.  It  is  absorbed  and  oxidized  to  indoxyl 
within  the  system,  where  it  unites  with  the  sulphuric  acid,  form- 
ing indoxyl-sulphuric  acid.  The  salt  of  indoxyl-sulphuric  acid 
with  which  we  have  to  do  is  the  indoxyl-sulphate  of  potassium 
(indican).  Another  substance,  indirubin,  allied  to  indican  and 
giving  a  red  color  with  the  same  test,  is  also  found,  but  its 
clinical  significance  is  unknown. 

Indican  in  very  small  quantity  may  normally  be  found  in  the 
urine,  seeming  to  depend  upon  the  character  of  the  food  ingested, 
being  increased  by  an  animal  diet ;  but  when  much  exists,  it  is 
always  pathologic. 

Causes. — Indican  may  be  found  whenever  there  is  any  large 
accumulation  of  putrid  (not  laudable)  pus  in  the  body,  and  when 
this  has  been  excluded,  its  presence  may  be  taken  to  indicate  an 
excessive  putrefaction  of  proteids  in  the  intestine  ;  by  far  its  most 
frequent  source.  As  an  instance  of  the  former  may  be  mentioned 
gangrenous  processes,  empyema,  and  peritonitis,  in  which  it  is 
often  a  grave  prognostic  sign.  According  to  Daland,  absence 
of  indicanuria  almost  precludes  a  diagnosis  of  peritonitis. 

Hochsinger  failed  to  find  it  in  the  new-born,  and  in  healthy 
infants  only  in  traces.  He  found  it  in  large  quantity  in  most 
intestinal  disturbances,  and  "  always  when  they  were  accom- 
panied with  acute  diarrhea  ;  also  in  tuberculosis,  whether 
involving  the  intestinal  tract  or  not."  He,  as  well  as  Gehlig, 
ascribed  it  to  the  putrefaction  of  milk  albumin  in  the  intestines. 

Singer  speaks  of  its  presence  in  urticaria  and  other  skin  dis- 
eases. Epilepsy,  particularly  at  the  time  of  seizure,  and  mas- 
turbation are  said  by  Herter  to  be  frequently  accompanied  with 
indicanuria.  The  most  common  conditions,  however,  with 
which  it  is  associated  are  chronic  intestinal  indigestion  and  con- 
stipation. 

Test. — Stokvis'  modification  of  Jaffe's  test,  performed  in  the 
following  manner,  will  serve  not  only  as  a  qualitative,  but  as  a 
fairly  accurate  quantitative,  test  for  clinical  purposes  : 

Urine  and  hydrochloric  acid  in  equal  parts  are  put  into  a  test- 
tube,  to  which  is  added  a  small  quantity  of  chloroform,  care 
being  taken  always  to  use  the  same  relative  quantity  of  urine, 
hydrochloric  acid,  and  chloroform  ;  for  in  this  way  only  can  the 
shades  of  color  of  the  chloroform  as  it  may  -vary  in  different  exam- 
inations be  taken  as  a  guide  to  the  increase  or  decrease  of  indican. 


288  DISEASES    OF    THE    GENITO-URINARY    SYSTEM. 

To  this  is  added  some  oxidizing  agent,  such  as  Labarraque's 
solution  or  solution  of  sodium  hypochlorite,  to  liberate  the 
indigo  ;  this  is  then  taken  up  by  the  chloroform,  which  assumes 
a  blue  color  varying  in  intensity  according  to  the  amount  of 
indican  present  in  the  urine. 

The  oxidizing  agent  should  be  added  one  drop  at  a  time,  and 
the  test-tube  thoroughly  shaken,  then  allowed  to  stand  a  few 
moments  for  the  reaction  to  take  place  before  adding  another, 
for  if  used  too  rapidly,  the  blue  color  will  be  bleached  when  there 
is  only  a  small  quantity  of  indican  present.  Slowly  in  this  way 
all  the  indigo  should  be  thrown  down. 

The  end  of  the  action  may  be  recognized  by  the  blue  color 
just  beginning  to  fade.  If  only  a  trace  of  indican  be  present, 
the  chloroform  may  remain  white  after  the  first  drop  of  hypo- 
chlorite, when  another  test  should  be  made,  using  only  the 
chloroform,  and  if  this  fails  to  show  any  trace  of  color,  the  tube 
may  be  set  aside  for  some  hours,  when  it  will  often  be  found  to 
show  distinctly. 

Precaution. — Care  must  be  taken  to  remove  any  albumin  pres- 
ent before  applying  the  test,  as  it  sometimes  gives  a  blue  color 
with  hydrochloric  acid  (Halliburton).  Bile  also  give's  a  muddy, 
greenish-blue  color  to  the  indican  reaction.  In  decomposed  urine 
the  indican  may  be  destroyed.  The  urine  of  patients  taking 
bromids  or  iodids  will  show  with  these  reagents  a  somewhat 
similar  reaction,  the  difference  being  that  in  the  case  of  the  iodids 
the  chloroform  is  colored  a  yellowish  red,  and  in  the  bromids  a 
reddish-violet  tint. 

Treatment. — The  indications  for  treatment  are  to  control  the 
putrefactive  process  going  on  in  the  intestinal  tract. 

ACETONURIA. 

Acetone  has  been  shown  by  von  Jaksch  to  be  derived  from 
the  proteids  both  of  the  body  and  of  the  food.  It  occurs  in 
normal  urine  only  in  traces,  but  pathologically  may  be  found  in 
large  quantity  in  many  diseased  conditions.  Most  commonly  it 
is  seen  accompanying  the  fevers  and  derangements  of  digestion, 
but  may  be  present  during  starvation,  with  psychoses  (Wagner), 
as  an  autointoxication,  in  advanced  stages  of  diabetes  mellitus, 
and,  according  to  von  Jaksch  and  others,  it  is  of  special  signifi- 
cance in  cases  of  grave  cerebral  irritation. 

Diacetic  Acid. — Diacetic  acid  never  occurs  in  normal  urine, 
but,  contrary  to  the  case  in  adults,  it  often  makes  its  appearance 
in  fevers,  when  it  is  of  no  serious  import.  When,  however,  it  is 


PYURIA  —  HEMATURIA.  289 

present  in  diabetes,  it  is  generally  a  warning  of  the  approach  of 
coma.  It  is  by  some  held  that  acetone  gives  rise  to  no  symp- 
toms, but  that  they  are  due  to  diacetic  and  oxybutyric  acids. 

PYURIA. 

Pus  may  come  from  any  part  of  the  urinary  tract,  or,  in  rare 
cases,  from  a  perinephritic  or  perityphlitic  abscess  opening  into 
some  portion  of  it,  but  in  children  its  most  frequent  source  is 
the  bladder  or  the  pelvis  of  the  kidney.  If  from  the  pelvis,  the 
pus  is  apt  to  be  in  large  quantity  and  perhaps  intermittent,  but 
if  due  to  calculus  or  to  tuberculous  pyelitis  it  is  continuous. 
The  urine  is  usually  acid  in  pyelitis,  whereas  in  cystitis  it  is  alka- 
line and  in  smaller  quantity.  Moreover,  there  will  be  the  charac- 
teristic symptoms  of  cystitis,  and  washing  out  the  bladder  will 
remove  any  doubt  that  may  still  exist.  If  from  the  urethra  or 
vagina,  the  local  symptoms  will  plainly  show  its  origin. 

When  the  pus  comes  from  a  source  outside  of  the  urinary 
tract  and  opening  into  it,  there  will  generally  be  local  or  consti- 
tutional symptoms  of  its  formation,  followed  by  its  sudden 
appearance  in  the  urine,  and  rapidly  disappearing  within  a  few 
days. 

The  treatment  is  merely  that  of  the  cause. 


HEMATURIA. 

Definition. — Hematuria  is  the  presence  in  the  urine  of  red 
blood-corpuscles. 

Causes. — It  may  result  from  the  use  of  drugs,  as  turpentine, 
cantharides,  and  carbolic  acid  ;  in  hemorrhagic  disease  of  the 
new-born,  hemophilia,  purpura,  scurvy,  rickets,  scarlatina, 
typhoid  fever,  variola,  leukemia,  malaria,  influenza,  filaria  san- 
guinis  hominis,  acute  inflammation  and  congestion,  tuberculosis, 
abscess,  and  tumors  of  the  kidneys,  and  in  renal  infarction  and 
calculus;  also  from  any  affection  or  injury  of  the  urinary  tract, 
such  as  the  passage  of  stone  along  the  ureters,  the  presence  in 
the  bladder  of  tumor,  stone,  or  ulceration,  and  from  the  urethra 
in  gonorrhea,  passage  of  stone,  or  use  of  the  catheter. 

Urine. — The  color  of  the  urine  may  vary  from  normal  to 
dark  reel,  depending,  of  course,  upon  the  amount  of  blood  pres- 
ent. The  corpuscles  may  be  intimately  mixed  with  the  urine,  or 
when  this  is  not  the  case,  may,  after  the  urine  has  been  allowed 
to  stand  for  some  time,  settle  to  the  bottom  of  the  vessel,  form- 
ing a  distinct  layer. 
19 


2QO  DISEASES    OF    THE    GENITOURINARY    SYSTEM. 

Under  the  microscope  the  corpuscles  may  appear  normal  in 
color  and  shape,  or  their  form  may  be  totally  changed  and  the 
color  gone,  appearing  only  as  faint  yellowish  rings. 

These  variations  help  to  distinguish  the  different  causes  which 
lead  to  their  appearance  in  the  urine  and  the  portion  of  the 
urinary  tract  in  which  the  hemorrhage  has  occurred.  They 
are  only  significant,  however,  when  taken  in  conjunction  with  the 
clinical  symptoms  and  a  further  examination  of  the  urine. 

Location  of  Hemorrhage. — When  the  blood  is  in  com- 
paratively large  quantity,  forming,  with  the  urine,  a  uniform 
smoky  or  reddish-brown  tint,  the  corpuscles  not  separating  out 
and  settling  to  the  bottom  of  the  vessel  in  a  more  or  less 
well-defined  stratum,  the  hemorrhage  may  be  considered  to  have 
taken  place  in  the  ureters,  pelvis  of  the  kidney,  or  in  the  kidney 
itself;  while,  on  the  other  hand,  when  it  is  from  the  bladder  or 
urethra,  the  blood  is  brighter  in  color  and  not  thoroughly  mixed 
with  the  urine. 

Kidneys. — The  urine  is  generally  acid  in  reaction,  of  lower 
specific  gravity,  and  of  homogeneous,  hazy  or  dark,  color,  pre- 
viously referred  to,  with  perhaps  long  narrow  molds  of  the  ureters. 
The  microscope  will  show  renal  epithelium  and  casts,  particu- 
larly blood-casts  ;  the  blood -corpuscles  are  variously  altered. 

Von  Jaksch  says  that  when  the  blood-cells  are  found  to  be 
intimately  mixed  with  the  urine  and  not  forming  a  sediment  after 
standing  for  some  hours,  but  deeply  coloring  the  urine,  and  the 
corpuscles  under  the  microscope  appear  profoundly  altered  and 
the  coloring-matter  is  lost,  they  probably  come  from  the  kidneys 
themselves,  and  the  symptoms  point  to  acute  nephritis  or  an 
exacerbation  of  chronic  nephritis.  When  they  appear  as  few 
attenuated  and  washed-out  rings,  they  may  have  originated  in 
congestive  states  or  in  miliary  tuberculosis  of  the  kidneys,  in  con- 
junction, of  course,  with  other  symptoms. 

To  distinguish  between  hemorrhage  from  the  pelvis  or  ureters 
is  sometimes  very  difficult.  Here  the  urine  is  generally  alkaline, 
and  characteristic  epithelium  must  be  looked  for  under  the  micro- 
scope, together  with  the  physical  signs  and  symptoms.  There 
may  also  be  clots,  molded  in  the  shape  of  the  ureters  or  pelvis. 

The  Bladder. — The  blood  is  brighter  in  color,  clots  are  more 
frequent,  and  the  urine  is  alkaline.  The  most  common  cause  is 
calculus,  and  the  blood  will  be  found  little,  if  any,  changed  from 
normal,  and  often  coming  only  at  the  end  of  micturition.  When 
ulceration  in  cystitis  gives  rise  to  the  hemorrhage,  there  will  be 
the  characteristic  symptoms  of  cystitis  :  ammoniacal  urine,  muco- 
pus,  etc. 


HEMOGLOBINURIA ENURESIS.  2QI 

If  uncertainty  still  exist,  the  bladder  may  be  washed  out,  and 
when,  after  repeated  washings,  the  fluid  comes  clear  and  free 
from  blood,  it  may  be  assumed  that  the  source  is  higher  up. 
The  cystoscope  may  be  used,  and  also  catheterization  of  the 
ureters  resorted  to. 

In  any  case,  however,  the  other  physical  signs  and  clinical 
symptoms  must  be  considered  before  making  a  positive  diagnosis. 

Diagnosis. — Heller's  and  Almen's  tests,  together  with  the 
appearance  of  red  blood-corpuscles  under  the  microscope,  should 
prevent  any  mistake  in  the  diagnosis  of  hematuria. 

Treatment. — The  treatment  is  directed  to  the  cause,  and  is 
the  same  as  in  the  adult. 

Frequently  in  children,  when  the  hematuria  is  of  renal  origin, 
recovery  takes  place  without  treatment  of  any  kind  except  rest. 

HEMOGLOBINURIA. 

Definition. — Hemoglobinuria  is  the  presence  in  the  urine  of 
blood  pigment. 

Causes. — The  destruction  of  the  red  blood-corpuscles,  setting 
free,  in  the  blood,  their  coloring-matter,  and  thence  its  passage 
into  the  urine,  is  caused  by  poisons,  such  as  potassium  chlorate, 
carbolic  acid,  CO2,  etc.,  and  in  certain  diseases  :  malaria,  scarla- 
tina, scurvy,  purpura,  typhoid  fever,  yellow  fever,  and  syphilis. 
There  is  also  an  epidemic  hemoglobinuria  of  the  new-born 
(Winckel's  disease)  and  a  paroxysmal  hemoglobinuria — a  peri- 
odic appearance  in  the  urine  of  blood  pigment  without  traceable 
cause.  It  may  sometimes  result  from  burns,  exposure  to  severe 
cold,  and  violent  exercise. 

Diagnosis. — The  urine  is  smoky  or  even  reddish  brown  or 
black  in  color,  acid  in  reaction,  and  albuminous.  The  micro- 
scope will  reveal  masses  of  pigment  and  perhaps  a  few  corpuscles, 
pale  in  color,  but  more  often  they  will  be  absent.  The  u rates 
also  may  be  stained  dark.  The  spectroscope  will  give  the  char- 
acteristic absorption  bands  of  methemoglobin  or  oxyhemoglobin, 
or  both. 

Treatment. — Treatment  is  unsatisfactory,  but  should  be  di- 
rected to  the  cause,  and  rest  enforced.  Amyl  nitrite  may  at 
times  be  of  service. 

ENURESIS. 
Synonym. — INCONTINENCE  OF  URINE. 

Definition. — Enuresis  is  a  condition  in  which  the  urine  is  in- 
voluntarily discharged  from  the  bladder.  It  may  appear  either 


DISEASES    OF    THE    GENITOURINARY    SYSTEM. 

during  the  day  or  night,  or  both.  It  may  be  periodic  or  continuous. 
During  early  infancy — that  is,  before  the  termination  of  the  first 
year  of  life — enuresis  may  be  described  as  a  physiologic  condi- 
tion, the  young  infant  possessing  no  control  over  the  bladder. 
After  this  time,  for  a  varying  period  dependent  upon  the  means 
employed  to  teach  the  child  to  control  its  bladder,  the  urine  will 
be  evacuated  at  stated  intervals,  and  the  involuntary  emptying 
of  the  bladder  may  be  regarded  as  a  symptom  of  some  patho- 
logic condition. 

Causes. — These  may  be  described  as  organic  and  functional. 
Among  the  former  we  have  malformations  of  the  kidneys,  ureters, 
or  bladder,  or  inflammations  of  any  of  these  organs.  Involun- 
tary evacuation  of  urine  may  also  be  a  symptom  of  various 
lesions  of  the  brain  or  spinal  cord.  In  the  largest  number  of 
cases_  enuresis  is  a  symptom  of  innutrition  or  malnutrition  or 
some  disturbance  of  the  equilibrium  of  metabolism,  and  symptoms 
of  such  disturbances  are  present  in  a  large  number  of  cases. 
Instances  of  this  may  be  found  in  rachitis  or  scrofuiosis,  or,  sec- 
ondarily, may  be  the  results  of  these  conditions  or  of  renal  or 
cardiac  disease.  In  another  group  the  evidences  are  less  pro- 
nounced, and  in  this  class  we  may  have  intestinal  disease,  lithu- 
ria,  or  polyuria.  In  a  third  class  the  exciting  cause  may  be 
more  obscure,  or  may  manifest  itself  simply  in  a  disturbance  of 
the  nervous  equilibrium,  shown  as  a  mild  or  a  severe  neurosis. 
In  this  class  of  cases  many  facts  the  result  of  clinical  observa- 
tion or  physiologic  research  lead  us  to  look  for  the  causes  of 
such  disturbances  in  the  highly  sensitive  nerve-cells. 

The  physiology  of  micturition  may  be  described  as  follows  : 
When  the  bladder  becomes  full,  an  impulse  passes  up  to  the 
cerebral  center  (see  diagram,  p.  293)  ;  an  inhibitory  impulse  is 
then  despatched  to  the  sphincter  center  in  the  fourth  lumbar 
segment.  The  impulse  then  passes  out  to  the  sphincter  urethrae, 
that  muscle  is  relaxed,  and  the  patient  voluntarily  contracts  the 
•abdominal  walls,  squeezing  a  few  drops  into  the  urethra.  These 
drops  generate  afferent  impulses  which  pass  to  another  center  in 
the  lumbar  cord — viz.,  the  motor  center  for  the  bladder- walls, 
or  the  "  detrusor  Center."  Afferent  impulses  continue,  and 
micturition  goes  on  as  a  reflex  act.  It  is  evident  that  if  we  cut 
off  the  cerebral  arc,  we  would  have  the  condition  seen  in 
enuresis.  This,  indeed,  is  the  condition  found  in  the  idiot  or 
imbecile,  or  in  children  in  whom  a  lesion  of  the  sensory  or  motor 
portions  of  the  cord  exists.  In  the  majority  of  cases  it  is  prob- 
able that  the  sphincter  center  in  the  fourth  lumbar  segment  is  at 
fault  (James  H.  McKee).  When  the  act  of  evacuation  of  the 


ENURESIS. 


293 


bladder  occurs  during  sleep,  at  which  time  the  inhibitory  influ- 
ence of  the  will  is  in  abeyance,  the  physiology  of  enuresis  is,  to 
some  extent,  the  same  as  when  the  cerebral  part  of  the  nervous 
system  is  at  fault  through  other  causes.  In  some  cases  the 
patient  may  dream  of  the  act,  and  the  evacuation  may  occur 
during  this  dream.  At  other  times  the  bladder  may  be  emptied 
without  any  knowledge  of  the  patient.  In  the  majority  of  cases 


Cere&ral 


FIG.  30. — DIAGRAM  SHOWING  REFLEX  NERVE  ARC  OF  THE  ACT  OF  MICTURITION.* 

the  sleep  is  abnormally  long  and  deep,  and  here  it  is  probable 
that  the  sphincter  centers  must  be  at  fault.  It  sometimes  happens 
that  the  incontinence  may  be  produced  by  a  reflex  irritation  set 
up  by  a  local  cause,  as  a  vesical  calculus,  a  cystitis,  or  vulvitis, 
or,  in  boys,  phimosis  and  balanitis,  an  elongated  or  adherent 
foreskin,  and  also  rectal  irritation.  Hyperacidity  of  the  urine 


*  For  a  thorough  description  of  the  physiology  of  micturition  see  article  by  Dr. 
James  H.  McKee,  "  University  Magazine,"  December,  1897. 


294  DISEASES    OF    THE    GENITOURINARY    SYSTEM. 

may  be  a  cause.  In  one  case  coming  under  the  care  of  one  of 
the  authors  the  enuresis  could  be  traced  directly  to  the  habitual 
drinking  of  coffee. 

The  symptoms  consist  in  the  involuntary  evacuation  of  the 
bladder. 

The  prognosis  depends  entirely  upon  the  cause.  In  a  certain 
proportion  of  cases  the  condition  will  not  last  for  a  very  long 
time,  yet  in  many  others  success  will  not  be  reached  except  by 
the  long-continued  administration  of  remedies  of  many  sorts, 
and  a  careful  and  thorough  investigation  as  to  the  cause  of  the 
trouble.  A  certain  proportion  of  cases  seem  to  baffle  all  our 
efforts,  continuing  for  months,  sometimes  with  long  periods  of 
intermission,  during  which  we  are  tempted  to  believe  them  cured, 
only  to  find  the  incontinence  returning.  A  case  of  enuresis 
should  not  be  considered  cured  until  several  months,  or  even  a 
year,  elapse  without  the  return  of  the  condition. 

Treatment. — No  matter  what  form  of  treatment  is  used,  the 
results  are  often  discouraging.  Patients  will  temporarily  improve  ; 
indeed,  may  seem  to  be  cured,  only  to  lapse  again  into  the  old 
condition.  On  the  other  hand,  spontaneous  cures  are  sometimes 
seen.  Occasionally  they  may  seem  to  result  from  nothing  more 
than  a  change  of  surroundings  or  of  diet.  Buckingham  speaks 
of  a  boy  upon  whom  various  methods  of  treatment  had  been 
tried  who  was  cured  during  a  vacation  in  which  he  cultivated  a 
taste  for  athletics.  There  is  no  class  of  cases  in  which  the  eti- 
ology should  be  more  carefully  studied  than  those  affected  by 
enuresis.  Central  and  spinal  lesions  and  various  malformations 
of  the  urinary  apparatus  must  be  sought  for.  The  urine  must 
be  constantly  examined,  and  if  found  to  be  highly  concentrated, 
the  patient  may  be  greatly  benefited — in  some  cases  absolutely 
cured — by  simply  diluting  it.  When  phimosis  is  a  cause,  it 
should  be  treated  by  the  methods  before  given.  Some  instances 
of  nocturnal  incontinence  of  urine  may  be  prevented  by  making 
the  child  empty  the  bladder  thoroughly  just  before  retiring  for 
the  night ;  or  if  the  incontinence  occurs  during  deep  sleep,  the 
child  may  be  awakened  once  or  twice  during  the  night  to  empty 
the  bladder.  There  are  instances,  too,  where  the  sleep  is  light 
and  shallow,  and  these  are  relieved  by  sulphonal  at  night.  When 
the  patient  has  a  highly  sensitive  vesical  sphincter,  it  may  be 
necessary  to  raise  the  foot  of  the  bed  so  as  to  keep  the  urine 
from  pressing  against  that  part.  A  regular  mode  of  life,  with 
outdoor  exercise,  is  especially  beneficial.  In  cases  of  lowered 
nerve  action  strychnin  is  indicated,  while  in  the  opposite  class  of 
cases,  those  with  extreme  irritability  of  the  nerve  centers,  bromids, 


STONE    IN    THE    BLADDER.  29 $ 

atropin,  and  belladonna  are  the  indicated  remedies.  These  drugs 
should  be  given  until  some  decided  symptoms  of  their  action 
are  manifested.  In  diseases  attended  by  congestion  the  use  of 
ergot  has  been  recommended.  Cold  douches  to  the  perineum  and 
faradism  have  been  of  some  use.  The  passage  of  a  cold  sound 
in  boys  is  recommended.  Urethral  electrization  is  often  effica- 
cious. Increasing  doses  of  atropin  or  hyoscin  hydrobromate  are 
the  most  reliable  measures. 


STONE  IN  THE  BLADDER. 

In  children  three  varieties  of  stone  are  met.  The  form  of  cal- 
culus in  the  bladder  most  frequently  found  is  that  known  as 
the  uric  acid  formation,  which,  according  to  statistics  quoted  by 
J.  William  White,  composes  from  two-thirds  to  five-sixths  of  all 
calculi  found  in  the  bladders  of  children.  This  variety  may  be 
made  up  entirely  of  uric  acid,  or  may  be  composite,  containing 
also  oxalate  of  lime  and  the  urates  of  ammonium  and  sodium. 
The  uric  acid  stone  is  usually  not  very  large  and  of  oval  shape, 
varying  in  color  from  a  yellowish  white  to  a  dark  brown.  Exter- 
nally this  form  of  calculus  maybe  smooth  or  slightly  roughened, 
while  on  section  it  is  found  to  be  laminated  or  amorphous.  The 
laminated  variety  is  extremely  hard,  and  capable  of  a  high  polish. 
The  amorphous  form  is  easily  broken,  and  resembles  coarse 
sand. 

The  second  variety  is  composed  of  oxalate  of  lime,  and  is 
sometimes  called  the  mulberry  calculus.  It  is  generally  round, 
covered  with  small  spicules,  and  its  color  varies  from  gray  to 
brownish  black. 

The  third  variety,  known  as  the  urate  of  ammonium  calculus, 
is  only  occasionally  found.  It  is  a  smooth,  flat,  oval  stone, 
brittle,  and  of  a  yellowish  color.  Other  varieties  of  calculus, 
such  as  the  mixed  phosphate  or  the  ammoniomagnesium  phos- 
phate and  those  composed  principally  of  phosphate  or  carbonate 
of  lime,  are  occasionally  seen.  Cystic  oxid,  xanthic  oxid,  and 
other  varieties  of  stone  have  been  described,  but  are  extremely 
rare.  The  size  of  vesical  calculi  varies  widely.  They  may  be 
single  or  multiple,  and  are  described  as  being  free  when  found 
loose  within  the  bladder,  and  attached  when  held  to  the  bladder- 
wall  either  by  a  fold  of  mucous  membrane  or  a  band  of  lymph 
(White). 

Causes. — But  little  is  known  as  to  the  cause  of  cystic  calculus 
in  children.  It  is  possible  that  an  inherited  gouty  tendency  may 
have  something  to  do  with  causation,  but,  on  the  other  hand,  it 


296  DISEASES    OF    THE    GENITOURINARY    SYSTEM. 

has  been  demonstrated  many  times  that  children  of  the  poor, 
or  those  having  few  of  the  luxuries  or  even  the  necessities  of 
life,  are  more  frequently  affected  than  children  born  in  better 
circumstances.  Boys  are  more  subject  to  stone  than  girls.  A 
predisposition  seems  to  run  in  certain  families,  and  the  inhabi- 
tants of  some  locations  are  more  frequently  affected  than  those 
of  others.  It  might  be  supposed  that  the  water-supply  of  a  cer- 
tain location  could  have  something  to  do  with  this,  yet  it  has 
been  proved  many  times  that  it  has  not.  Race  seems  to  have 
some  influence,  it  having  been  shown  that  the  negro  is  affected 
far  less  frequently  than  the  white  races. 

In  almost  every  case  stone  has  its  origin  in  the  kidney,  and  it 
is  believed  that  the  uric  acid  infarcts  so  often  seen  in  the  kidneys 
of  newly  born  children  form  the  first  stage  in  the  production  of 
calculus,  and  that  the  large  quantity  of  uric  acid  which  is  present 
in  early  life  will  explain  the  frequency  of  this  form  of  calculus, 
or  its  presence  may  act  as  a  nucleus  of  other  forms  of  calculi 
which  may  later  develop  in  the  bladder.  Occasionally  the  stone 
may  be  formed  around  a  nucleus  which  is  composed  of  some 
foreign  body  which  has  been  passed  into  the  bladder.  This  is, 
however,  very  rare. 

Symptoms. — The  group  of  symptoms  which  points  to  the 
presence  of  renal  calculus  is  in  most  respects  the  same  in  chil- 
dren as  in  adults.  In  many  cases  the  first  evidence  of  its  pres- 
ence will  be  shown  by  an  attack  of  intense  pain,  accompanying  a 
group  of  symptoms  known  as  nephritic  colic.  In  the  midst  of 
health  the  child  is  suddenly  attacked  by  violent  pain,  first  felt  in 
the  lumbar  or  hypochondriacal  region,  and  extending  toward  the 
scrotum  and  end  of  the  penis.  The  testicle  on  the  side  affected 
will  be  drawn  up  by  a  spasm  of  the  cremaster  muscle.  Pain  is 
also  felt  in  the  groin  and  thigh  on  the  affected  side.  The  patient 
has  a  continual  desire  to  pass  water.  The  attack  of  colic  is 
accompanied  by  sweating,  which  is  profuse,  and  the  skin  becomes 
cold  and  clammy.  Pain  may  be  so  intense  as  to  cause  convul- 
sions and  collapse.  The  urine  is  passed  frequently,  but  in  small 
amounts,  and  is  very  highly  colored.  Actual  suppression  may 
occur  as  the  stone  makes  its  progress  along  the  ureter,  and  will 
only  cease  permanently  when  it  has  reached  the  bladder,  at 
which  time  the  pain  also  ceases  suddenly.  After  the  stone  has 
reached  the  bladder,  the  foregoing  group  of  symptoms  give  place 
to  others. 

The  principal  symptom  of  stone  in  the  bladder  is  increased  fre- 
quency of  urination.  The  desire  to  evacuate  the  bladder  may  be 
continuous,  amounting  to  actual  incontinence.  This  symptom  is 


STONE    IN    THE    BLADDER. 

worse  by  day,  when  the  patient  is  up  and  around,  than  at  night. 
It  is  increased  by  motion,  and  its  amount  depends  to  a  certain 
extent  on  the  shape  of  the  stone.  Occasionally  retention  of 
urine  occurs.  This  may  be  produced  either  by  the  stone  acting 
as  a  ball-valve  and  stopping  the  flow  of  urine,  or,  in  some  rare 
instances,  is  reflex.  The  pain  is  of  a  darting,  burning  character, 
increased  during  urination,  particularly  at  the  termination.  It  is 
caused  by  the  mucous  membrane  of  the  bladder  coming  in  con- 
tact with  the  stone.  The  pain,  however,  is  rarely  felt  in  the 
bladder,  but  is  referred  to  the  under  surface  of  the  penis  some 
distance  behind  the  external  meatus.  It  is  often  so  severe  as  to 
cause  convulsions.  It  continues  until  a  sufficient  amount  of 
urine  has  collected  in  the  bladder  to  raise  the  mucous  membrane 
away  from  the  stone.  Various  reflex  pains,  referred  to  different 
parts  of  the  body,  are  not  infrequently  associated  with  vesical 
calculus  ;  these  may  be  felt  in  the  rectum  or  perineum,  and 
occasionally  in  various  parts  of  the  body  far  removed  from  the 
seat  of  the  trouble.  From  the  constant  irritation  of  the  penis 
the  habit  of  masturbation  may  be  set  up,  or  from  handling  of 
the  parts  the  foreskin  may  be  rendered  abnormally  long,  while 
in  some  cases  phimosis  or  paraphimosis  is  produced  by  this  cause. 
Cystitis  is  almost  always  present.  From  the  constant  efforts  at 
straining  prolapse  of  the  rectum  may  be  produced.  When  the 
flow  of  urine  is  stopped  by  the  calculus  obstructing  the  vesical 
orifice,  the  child  may  assume  various  peculiar  positions  while 
evacuating  the  bladder,  in  order  to  cause  the  stone  to  fall  away 
from  the  opening  of  the  urethra  and  allow  the  passage  of  urine. 
Hematuria  may  occur,  but  is  rarer  in  children  than  in  adults. 
As  sequelae  we  very  frequently  note  chronic  cystitis,  and  some- 
times pyelitis.  Dilatation  of  the  ureters  may  occur,  and  from 
extension  of  inflammation  there  may  arise  nephritis  or  even 
suppurative  pyelitis. 

Diagnosis. — Stone  in  the  bladder  may  be  confounded  with 
one  of  several  conditions.  The  diseases  most  likely  to  be  mis- 
taken for  it  are  a  contraction  of  the  urinary  meatus,  cystitis, 
phimosis,  the  condition  known  as  irritable  bladder,  vesical 
tumors,  and  renal  calculus.  None  of  these  conditions  will,  how- 
ever, show  a  group  of  symptoms  so  severe  and  well  marked  as 
stone.  The  surest  factor  in  diagnosis,  however,  is  the  finding  of 
the  stone  by  examination  by  means  of  a  sound. 

In  all  cases  of  irritability  of  the  bladder  in  children,  especially 
when  there  is  pain  during  or  immediately  following  the  act  of 
urination,  and  when  phimosis  or  malformation  of  the  penis  and 
urethra  does  not  exist,  the  bladder  should  be  carefully  examined 


298  DISEASES    OF    THE    GENITOURINARY    SYSTEM. 

for  stone.  It  is  best  to  administer  an  anesthetic,  in  order  to 
produce  complete  relaxation  of  the  part  and  to  prevent  the  child 
from  struggling  and  possibly  receiving  injury  at  the  time  of 
examination.  The  bladder  should  then  be  filled  with  warm  solu- 
tion of  boric  acid,  to  distend  the  walls  and  give  greater  space  for 
the  movements  of  the  searcher.  By  the  careful  use  of  a  sound 
in  the  bladder  the  presence  of  a  stone  can  readily  be  demon- 
strated by  the  characteristic  "  click  "  which  the  instrument  makes 
in  coming  in  contact  with  the  stone.  Sometimes  this  sound  can 
be  heard  some  distance  from  the  patient. 

The  treatment  is  surgical  :  either  by  crushing  (lithotrity)  or 
lithotomy.  If  the  stone  be  small,  or  even  of  moderate  size,  it 
may  be  crushed  by  a  lithotrite  and  evacuated  at  one  sitting — 
as  is  done  in  adults.  Of  late  years  this  mode  of  operating  has 
been  very  extensively  practised,  with  admirable  results.  Piperazin 
as  a  solvent  of  uric  acid  stone  has  been  largely  used,  with  con- 
flicting reports  as  to  results.  D.  D.  Stewart  has  reported  toxic 
symptoms  from  its  employment  in  adults,  and  recommends,  for 
a  child  of  ten  years,  that  the  dose  be  not  over  2^  grains. 


CYSTITIS. 

Inflammation  of  the  mucous  membrane  of  the  bladder  is  much 
rarer  during  infancy  and  childhood  than  in  adult  life. 

Causes. — The  most  common  cause  of  vesical  inflammation  is 
stone.  It  may  also  be  produced  by  a  retention  of  urine  within 
the  bladder,  caused  by  a  contracted  meatus  and  from  phimosis. 
The  long-continued  administration  of  irritating  drugs  may  pro- 
duce it,  or  a  growth  within  the  meatus  may  act  as  a  causal 
factor.  A  form  of  very  severe  cystitis  may  appear  in  the  course 
of  tuberculosis  in  children,  and  is  due  to  tuberculous  infection 
of  the  bladder.  Occasionally  it  is  produced  by  an  extension 
into  the  bladder  of  any  infection  from  without. 

Symptoms. — The  symptoms  of  cystitis  in  children  are  practi- 
cally the  same  as  those  in  the  adult.  There  is  some  rise  of  tem- 
perature and  fretfulness.  Indeed,  the  child  may  appear  quite  ill. 
Micturition  is  frequent  and  painful,  the  urine,  which  is  passed  in 
small  quantities,  is  viscid,  from  pus  and  mucus,  alkaline  or  mildly 
acid  in  reaction,  and,  if  acid  when  voided,  promptly  undergoes 
decomposition,  becoming  strongly  alkaline,  converting  the  con- 
tained pus  into  a  thick,  mucilaginous  mass  —  a  characteristic 
and  diagnostic  sign.  The  microscope  will  show  crystals  of  triple 
phosphates  and  amorphous  phosphates  of  lime,  pus-cells,  epi- 


CYSTITIS.  299 

thelium,  and,  in  the  severer  cases,  especially  if  caused  by  calculus, 
blood-corpuscles. 

Chronic  cystitis  arises  very  commonly  from  stone  in  the  blad- 
der or  the  presence  of  foreign  bodies — a  tumor — or  tuberculosis. 
The  acute  form,  unmitigated  by  treatment,  may  progress  into  the 
chronic  variety. 

The  symptoms  are  painful  and  frequent  micturition,  the  pas- 
sage of  urine  later  becoming  almost  constant,  and  associated  with 
an  irritation  of  the  external  genital  organs,  caused  by  an  am- 
moniacal  condition  of  the  urine.  Prolapse  of  the  rectum  is  very 
commonly  associated,  from  constant  straining,  when  the  irritation 
is  caused  by  the  presence  of  a  stone.  The  urine  is  subject  to  the 
same  changes  as  in  the  acute  form. 

Prognosis. — In  the  acute  form  the  prognosis  is  good,  providing 
the  cause  can  be  removed.  When  prompt  treatment  is  not  insti- 
tuted, the  condition  rapidly  passes  into  the  chronic  form,  which 
is  very  persistent  and  hard  to  control.  The  outlook  for  cure  in 
the  chronic  form  depends  very  much  upon  the  cause  and  the 
duration  of  the  attack.  It  must  not  be  forgotten  that  cystitis 
may  appear  as  a  secondary  consequence  of  diseases  of  the  kid- 
neys. The  cause  of  the  disease  must  always  be  sought  for  and 
removed  if  possible.  The  patient  should  be  kept  at  rest  in  bed. 
The  diet  should  consist  of  milk.  Water  should  be  given  freely, 
and  various  diluent  drinks,  such  as  flaxseed  tea,  mucilage  of  acacia, 
and  the  citrate  or  acetate  of  potash,  may  also  be  made  use  of. 
The  bowels  should  be  thoroughly  opened  by  salines.  Poultices 
or  hot  fomentations  should  be  placed  over  the  bladder.  If  there 
is  much  pain,  opium  may  be  used  by  suppository  or  enema,  but 
it  must  be  remembered  that  this  drug  should  be  given  with  great 
caution  to  children.  Various  other  agents  may  be  employed, 
such  as  tincture  of  aconite,  the  spirits  of  nitrous  ether,  benzoate 
of  sodium,  etc.  Tyson  recommends,  when  great  irritation  is 
present,  injections  into  the  bladder  of-  cocain  :  for  an  adult  not 
more  than  two  grains  at  one  time.  This  must  be  used  cautiously 
in  children  and  in  much  smaller  doses. 

In  chronic  cystitis  the  bladder  should  be  washed  out  once  or 
even  twice  daily,  if  necessary,  with  warm  water,  to  which  may  be 
added  boric  acid,  one  dram  to  the  pint.  It  should  be  injected 
slowly  in  small  quantities  at  a  time,  according  to  the  capacity  of 
the  child's  bladder,  and  repeated  until  the  water  comes  away 
clear.  The  water  should  be  at  a  temperature  of  about  100°  F. 
Urotropin  and  cystogen  are  useful  in  older  children,  in  doses  of 
a  grain  or  more  three  or  four  times  daily,  well  diluted. 


3OO  DISEASES    OF    THE    GENITOURINARY    SYSTEM. 


PHYSIOLOGIC  ALBUMINURIA. 

It  is  pretty  generally  held  now  that  occasionally  there  may  be 
an  appearance  of  albumin  in  the  urine  that  is  physiologic,  but 
before  such  a  diagnosis  is  made  care  must  be  taken,  first,  that  in 
performing  the  tests  it  is  serum  albumin  that  is  found  and  not  any 
of  the  other  proteid  bodies,  such,  for  instance,  as  nucleo-albumin. 
This  may  seem  at  first  sight  a  needless  caution,  but  with  some 
of  the  more  recent  and  sensitive  reagents  a  reaction  similar  to 
albumin  is  sometimes  shown  with  even  distilled  water  which  has 
been  passed  through  Swedish  filter-paper,  the  albumin  of  the 
paper  being  responsible  for  it. 

Furthermore,  the  albumin  in  these  cases  is  always  in  small 
amount.  The  examinations  must  be  continued  over  a  consider- 
able period  of  time,  and  the  urine  should  show  no  other  changes 
from  the  normal,  such  as  casts,  and  the  elimination  of  urea  must 
show  little  or  no  diminution  in  quantity  ;  and  further,  to  exclude 
the  possibility  of  any  renal  changes,  there  should  be  found  no 
such  characteristic  symptoms  as  dropsy  (in  any  degree),  a  pulse 
of  high  tension,  nor  evidence  of  cardiac  hypertrophy.  ,  By  some 
it  is  claimed  that  no  alteration  has  taken  place  in  the  epithelium 
lining  the  capillaries  of  the  tufts  or  of  the  glomeruli,  while  others 
contend  that  it  is  always  in  a  state  of  "  cloudy  swelling." 

There  occurs  what  is  termed  a  "cyclic  albuminuria"  where 
albumin  can  be  demonstrated  during  the  day  but  is  absent  from 
the  urine  secreted  during  the  night.  The  erect  posture  has  been 
offered  as  an  explanation.  There  is  an  occasional  albuminuria 
that  is  associated  with  an  oxaluria,  and  Trissier  has  noticed  it  in 
young  children  of  gouty  parentage,  generally  boys. 

Among  the  causes  said  to  produce  it  are  an  albuminous  diet, 
violent  exercise  or  emotion,  and  cold  bathing.  At  times  there 
may  be  no  traceable  cause. 

Treatment. — The  treatment  consists  in  the  removal  of  the 
cause,  where  one  exists,  and  the  building  up  of  the  patient  on 
general  lines. 


CHRONIC    CONGESTION    OF    THE    KIDNEY.  30! 


DISEASES  OF  THE   KIDNEY. 

ACUTE  CONGESTION  OF  THE  KIDNEY. 
Synonyms. — RENAL  HYPEREMIA  ;  ACUTE  RENAL   CATARRH. 

Causes. — Acute  renal  congestion  may  occur  as  the  result  of 
traumatism  from  the  use  of  certain  irritating  drugs — such  as 
turpentine  or  cantharides — or  from  cold.  The  most  common 
cause  is  the  acute  infectious  diseases. 

Pathology. — The  blood-vessels  of  the  kidney  are  engorged 
with  blood,  and,  owing  to  this  congestion,  there  is  frequently  an 
escape  of  serum,  red  blood-cells,  and  leukocytes.  The  epithelium 
of  the  parenchyma  is  in  a  state  of  "  cloudy  swelling." 

Symptoms. — The  symptoms  of  renal  congestion  itself  are 
rather  varied.  There  are  generally  some  headache,  pain  in  the 
back,  and  general  malaise.  The  urine  is  scanty,  highly  colored, 
from  the  presence  of  red  blood-cells  or  blood-casts,  and  of  high 
specific  gravity.  It  always  contains  some  albumin.  This  may 
differ  markedly  in  amount.  The  duration  of  the  attack  may  vary 
considerably. 

The  prognosis  will  depend  entirely  upon  the  cause  of  the  con- 
gestion and  whether  or  not  the  congestion  proves  to  be  the 
beginning  of  an  attack  of  acute  nephritis. 

Treatment. — The  bowels  should  be  freely  opened,  preferably 
by  the  use  of  salines  or  calomel ;  the  latter  is  especially  useful 
on  account  of  its  diuretic  action.  Hot  vapor  baths  should  be 
employed  to  produce  diaphoresis.  Mild  counterirritation  over 
the  kidneys  by  means  of  dry  cups  or  hot  poultices  is  to  be 
employed.  When  irritability  of  the  bladder  is  present  camphor 
may  be  used,  or  in  some  cases  small  doses  of  camphorated  tinc- 
ture of  opium  may  be  given  with  benefit. 

CHRONIC  CONGESTION  OF  THE  KIDNEY. 

Causes. — Chronic  renal  congestion  may  be  produced  by  the 
continuance  of  the  acute  form.  It  is  most  frequently  met  as  the 
result  of  an  interference  with  the  return  circulation  of  the  kidney, 
which  may  appear  during  an  attack  of  heart  disease.  It  is  also 
very  common  in  chronic  bronchial  pneumonia  or  chronic  pleu- 
risy. It  may  be  found  when  this  circulation  is  interfered  with  by 
reason  of  an  abdominal  tumor,  also  by  thrombosis  of  the  renal 
vein. 

Pathology. — The   kidneys  are  enlarged  in  early  stage  ;  later 


3O2  DISEASES    OF    THE    GENITOURINARY    SYSTEM. 

they  become  normal  in  size,  darker  colored  than  normal,  and 
of  firmer  consistency.  The  entire  organ  is  distended  with  blood. 
The  capillary  vessels  are  engorged,  their  walls  being  thickened. 

Symptoms. — General  dropsy  is  a  common  feature,  together 
with  the  symptoms  of  the  disease  causing  it.  The  urine  is 
always  scanty  and  of  high  specific  gravity,  containing  usually 
a  small  amount  of  albumin.  The  microscope  will  reveal  the 
presence  of  a  few  small  hyaline  or  granular  casts.  These  may 
not,  however,  be  regularly  present.  The  bowels  are  generally 
constipated  ;  irritability  of  the  bladder  is  commonly  present. 
Uremia  is  very  infrequent. 

Treatment. — In  addition  to  the  treatment  of  the  condition 
causing  the  congestion,  an  effort  should  be  made  to  increase  the 
amount  of  urine  by  the  use  of  digitalis,  especially  the  infusion  ; 
camphorated  tincture  of  opium,  either  alone  or  combined  with 
sweet  spirits  of  niter  ;  the  alkaline  diuretics,  caffein,  and  other 
drugs  of  the  same  order.  The  bowels  should  be  kept  open  by 
salines  and  hot  baths,  or  vapor  baths  should  be  used  to  promote 
diaphoresis.  When  the  amount  of  urine  passed  is  extremely 
small,  nitroglycerin  may  be  used  with  benefit.  Suitable  dietetic 
and  hygienic  measures  should,  of  course,  be  employed. 

ACUTE  DEGENERATION  OF  THE  KIDNEY. 

Causes. — Acute  degeneration  of  the  kidneys  is  very  fre- 
quently present  in  the  course  of  acute  infectious  diseases,  but  it 
is  found  oftenest  and  is  most  marked  in  cases  of  diphtheria, 
scarlet  fever,  and  acute  pleural  pneumonia.  It  may  appear  dur- 
ing the  course  of  any  disease  accompanied  by  long-continued 
high  temperature.  In  all  probability  it  is  caused  by  direct  irrita- 
tion of  the  epithelium  of  the  tubules  by  toxins  eliminated  by  the 
kidneys.  Irritating  drugs  may  also  produce  it. 

Pathology. — The  color  of  the  kidney  is  pale,  and  the  whole 
organ  is  somewhat  enlarged.  The  cortex  is  thickened,  and  the 
straight  tubules  are  marked  by  yellowish-gray  lines.  The  epi- 
thelium of  the  tubules  undergoes  granular  degeneration.  Some 
exudation  of  serum  may  take  place. 

Symptoms. — There  are  no  special  symptoms  connected  with 
this  form  of  renal  disease  other  than  those  which  accompany  dis- 
eases producing  it.  The  urine  will  contain  a  moderate  amount 
of  albumin  and  sometimes  a  few  granular  and  hyaline  casts. 

Treatment  should  consist  in  the  use  of  a  liquid  diet  and 
diuretics,  in  addition  to  the  treatment  of  the  condition  producing 
the  degeneration. 


ACUTE    EXUDATIVE    NEPHRITIS.  303 

ACUTE  EXUDATIVE  NEPHRITIS. 

Synonyms. — ACUTE  PARENCHYMATOUS  NEPHRITIS  ;    ACUTE  SEPTIC 
INTERSTITIAL  NEPHRITIS  ;  ACUTE  DESQUAMATIVE  NEPH- 
RITIS ;    ACUTE   TUBULAR    NEPHRITIS. 

Definition. — Acute  exudative  nephritis  is  an  inflammation  of 
the  true  renal  epithelium.  In  the  majority  of  cases  it  is  either 
directly  or  indirectly  of  septic  origin. 

Causes. — This  variety  of  nephritis  is  very  common  among 
infants  and  children  of  all  ages.  It  is  most  frequently  seen  as  a 
secondary  affection  appearing  in  the  course  of,  or  following  an 
attack  of,  the  acute  infectious  diseases,  especially  scarlet  fever 
and  diphtheria.  Occasionally  it  follows  an  attack  of  typhoid 
fever,  measles,  varicella,  scurvy,  meningitis,  influenza,  and  the 
acute  diarrheal  diseases.  Various  irritating  drugs  and  traumatism 
may  occasionally  produce  it.  It  is  possible  that  in  some  cases 
occurring  in  infants  the  septic  infection  causing  the  disease  may 
occur  through  the  umbilicus,  as  in  the  case  reported  by  E.  H. 
Root. 

Pathology. — In  infants  and  young  children  the  predominant 
pathologic  feature  is  the  exudation  of  leukocytes.  The  renal 
epithelium  and  glomeruli  undergo  inflammatory  changes.  There 
is  an  exudation  of  blood  plasma  with  leukocytes  and  red  blood- 
cells.  Enlargement  of  the  kidney  occurs,  the  whole  organ  being 
softened  and  edematous.  The  most  marked  changes  occur  in 
the  cortex,  which  is  thickened  and  is  usually  of  a  yellowish-white 
color,  sometimes  mottled  or  speckled  with  red,  due  to  small 
hemorrhages.  Occasionally  the  entire  organ  is  congested.  Sec- 
tion of  the  kidney  will  show  in  some  cases  that  the  inner  portion, 
as  well  as  the  surface,  may  be  mottled  with  small  yellow  spots, 
each  spot  being  a  small  collection  of  pus.  These  small  abscesses 
may  vary  in  size  from  that  of  a  pin's  head  to  that  of  a  pea.  On 
microscopic  examination  the  tubular  epithelium  will  be  swollen, 
loosened,  and  degenerated.  The  tubules  themselves  may  be 
dilated,  and  may  contain  red  and  white  blood-cells  and  degener- 
ated epithelium.  Marked  changes  occur  in  the  glomeruli.  The 
cells  covering  the  capillary  tufts,  and,  indeed,  the  capillaries 
themselves,  undergo  swelling  and  proliferation.  The  cavities  of 
the  capsules  frequently  contain  masses  of  red  and  white  blood-cells, 
and  the  smaller  blood-vessels  may  contain  bacteria.  The  stroma 
and  venous  capillaries  contain  accumulations  of  leukocytes,  occur- 
ring usually  in  irregular  patches.  No  blood  serum  may  accom- 
pany the  transudation  of  leukocytes,  and  for  this  reason  the  urine 
may  contain  no  albumin.  In  all  his  postmortem  examinations 


304  DISEASES    OF    THE    GENITO-URINARY    SYSTEM. 

Holt  states  that  the  most  prominent  feature  in  nephritis  in  young 
infants  was  the  excessive  exudation  of  leukocytes. 

Symptoms. — Two  forms  of  the  disease  are  usually  recognized, 
the  primary  and  the  secondary.  In  the  primary  form  the  severity 
of  the  symptoms  will  depend  very  much  on  the  age  of  the  patient, 
the  disease  being  much  more  dangerous  in  infants  and  young 
children.  In  the  primaiy  form  occurring  in  infants  the  symptoms 
are  often  obscure  ;  so  much  so,  indeed,  that  the  origin  of  the  dis- 
ease may  be  misunderstood.  The  attack  begins,  in  the  majority 
of  cases,  abruptly,  with  high  fever  and  vomiting,  the  tempera- 
ture very  often  rising  as  high  as  103°  to  104°  F.  ;  in  bad  cases 
it  may  even  reach  105°  F.  The  type  is  usually  irregular.  Holt 
states  that  in  his  own  cases  and  in  those  which  he  has  collected 
from  the  experience  of  others  diarrhea  and  vomiting  were  noticed 
in  half  the  number  of  cases  observed.  Dropsy  may  exist  to  a 
slight  degree,  but  is  very  often  absent.  Anemia  is  a  prominent 
symptom,  being  present  in  nearly  every  case.  This  is  consid- 
ered a  valuable  diagnostic  point.  The  nervous  symptoms  are 
usually  quite  prominent.  These  consist  of  restlessness,  twitching 
of  the  muscles,  or,  in  more  marked  cases,  even  convulsions.  On 
the  other  hand,  the  mind  may  be  dull  and  apathetic.  True 
uremic  coma  is  very  seldom  seen.  The  duration  of  the  disease 
will  vary  from  eight  days  to  four  weeks,  the  average  being  about 
two  and  a  half  weeks.  Cases  progressing  to  a  fatal  termina- 
tion may  develop  symptoms  of  a  true  typhoid  condition.  The 
urine  is  slightly  decreased  in  quantity  in  the  majority  of  cases  ; 
when  the  attack  is  severe,  however,  the  amount  passed  may  be 
much  smaller  than  normal,  and,  indeed,  actual  suppression  may 
occasionally  occur.  Albumin  is  generally  present  in  the  early 
part  of  the  attack  and  always  during  a  later  period.  The  quantity 
is  usually  not  great.  Microscopic  examination  of  the  urine  will 
show  the  presence  of  hyaline,  granular,  and  epithelial  casts. 
Blood-casts  are  rare.  Examination  will  also  demonstrate  the 
presence  of  pus-cells  and  renal  epithelial  cells,  with  some  red 
blood-corpuscles.  In  older  children  the  disease  is  much  less 
severe,  and  the  outlook  for  a  favorable  termination  is  better. 
The  attack  begins  less  abruptly  and  the  febrile  symptoms  are 
less  marked.  Dropsy  is  slight,  or,  indeed,  may  be  absent  alto- 
gether. The  urine  is  slightly  diminished  in  quantity,  and  the 
amount  of  albumin  much  less.  Casts  may  be  present — usually 
the  varieties  before  described.  The  general  symptoms  are  much 
milder  than  in  the  form  seen  in  infants. 

The  secondary  form  of  the  disease  usually  appears  during  the 
course  of  one  of  the  infectious  diseases.  The  constitutional 


ACUTE    DIFFUSE    NEPHRITIS.  305 

symptoms  are  often  not  marked.  The  urine  may  be  somewhat 
diminished,  and  the  microscopic  appearances  are  about  the  same 
as  those  in  the  two  preceding  varieties. 

Prognosis. — Holt  states  that  in  the  twenty-three  cases  inves- 
tigated in  which  the  disease  occurred  in  infants  the  mortality  was 
fifteen  ;  and  in  his  own  cases,  nine  in  number,  eight  died. 

Treatment. — The  treatment  is  the  same  as  in  other  forms. 


ACUTE  DIFFUSE  NEPHRITIS. 

Synonyms. — ACUTE  GLOMERULONEPHRITIS  ;  ACUTE  BRIGHT'S 

DISEASE. 

Causes. — In  the  majority  of  cases  acute  diffuse  nephritis  fol- 
lows an  attack  of  one  of  the  infectious  diseases,  particularly 
scarlet  fever,  in  which  case  it  is  generally  admitted  that  the 
exciting  cause  can  be  attributed  to  the  scarlatinal  poison,  proba- 
bly the  result  of  direct  irritation  from  the  toxins  of  the  disease. 
It  sometimes  follows  diphtheria,  when  the  exciting  cause  is 
probably  toxemic,  the  action  of  the  poison  being  similar  to  the 
scarlatinal  complication.  Cold  and  exposure  have  been  attributed 
as  causes,  and  in  some  cases  the  etiology  is  obscure.  As  pre- 
disposing causes  of  the  postscarlatinal  variety  it  has  been  stated 
that  allowing  the  patient  to  get  up  too  soon  after  the  disease  or 
the  too  early  administration  of  solid  foods  has  a  tendency  to  aid 
in  the  irritation  of  kidneys  previously  weakened  by  the  scarlatinal 
poison.  The  frequency  of  the  disease  as  a  sequela  of  scarlet 
fever  varies  considerably  with  epidemics.  Blows  and  injuries  of 
the  back  have  also  been  given  as  causes.  The  acute  diffuse 
nephritis  is  much  more  frequently  seen  in  children  and  young 
adults  than  in  the  old. 

Pathology. — The  main  points  in  the  morbid  anatomy  of  the 
kidneys  are  as  follows  :  The  entire  organ  is  enlarged,  often  to  a 
considerable  extent,  and  is  softer  than  normal.  In  the  early 
stages  of  the  disease  the  kidneys  are  sometimes  considerably 
congested,  but  after  the  disease  is  well  established,  they  are  a 
yellowish-white  color  mottled  with  red.  Thickening  of  the  cor- 
tex occurs,  this  portion  being  usually  yellow,  and  showing  a  dis- 
tinct contrast  to  the  pyramids,  which  are  red.  Microscopic 
examination  shows  the  characteristic  changes  of  this  variety  of 
nephritis,  which  consist  in  the  formation  of  connective-tissue 
cells  in  the  stroma  and  proliferation  of  the  cells  forming  the 
capsule  of  the  Malpighian  bodies.  The  longer  the  duration 
of  the  disease,  the  denser  and  more  fibrous  in  character  will  the 


306  DISEASES    OF    THE    GENITOURINARY    SYSTEM. 

connective  tissue  appear.  Finally,  the  glomeruli  undergo  per- 
manent change  ;  the  tufts  will  be  reduced  by  the  growth  of  the 
endothelial  cells  lining  the  capsule,  which  may  ultimately  form 
new  fibrous  tissue. 

Symptoms. — The  primary  form  of  acute  diffuse  nephritis  may 
begin  suddenly,  with  fever,  the  temperature  often  rising  to  101° 
or  102°  F.,  and  when  the  attack  is  severe  it  may  rise  much 
higher.  There  are  pain  in  the  lumbar  region,  headache,  vomit- 
ing, and  decrease  in  the  amount  of  urine.  Dropsy  is  present  in 
the  majority  of  cases.  Occasionally  the  onset  is  slower  and  the 
symptoms  less  severe,  the  dropsy  appearing  slowly  and  the  urine 
gradually  decreasing  in  amount.  The  postscarlatinal  form  begins 
insidiously :  usually  in  the  third  or  fourth  week  of  the  disease. 
In  this  form  moderate  fever,  scanty  urine,  and  dropsy  are  the 
principal  symptoms.  The  dropsy  manifests  itself  in  a  manner 
which  is  almost  characteristic ;  in  amount  it  is  well  marked  ;  it 
usually  appears  in  the  face,  then  in  the  feet,  from  which  it 
ascends  up  the  leg,  and  may  even  effect  the  scrotum  or  external 
labia.  It  may  continue  to  progress  over  the  whole  body,  gener- 
ally producing  anasarca.  Serous  effusions  into  the  pleura  or 
peritoneum,  and  more  rarely  into  the  pericardium,  may  occur. 
Anemia  is  very  often  present ;  always  if  the  disease  is  well 
marked.  In  cases  of  some  duration  the  skin  assumes  a  peculiar 
waxy  appearance  which  is  one  of  the  characteristics  of  the 
disease. 

The  Urine. — As  a  rule,  this  is  considerably  diminished  in 
quantity ;  indeed,  suppression  is  not  uncommon.  Albumin  is 
always  present  in  large  amounts.  The  color  of  the  urine  is 
smoky  or  reddish  brown,  due  to  the  presence  of  red  blood- 
globules  or  hemoglobin.  The  specific  gravity  at  first  may  be 
high,  but  later  is  generally  low ;  the  amount  of  urea  eliminated 
is  below  normal.  The  microscope  shows  the  presence  of  casts  in 
great  variety.  Hyaline,  granular,  and  epithelial  casts  are  always 
present,  and  pus-,  mucus-,  and  blood-casts  are  not  rare.  Chlorids 
and  earthy  phosphates  are  at  first  diminished.  Hematin,  indi- 
can,  and  uric  acid  show  an  increase  (Tyson).  Leukocytes  and 
red  blood-cells,  with  a  large  variety  of  cells  from  the  renal 
epithelium,  are  present.  In  cases  of  ordinary  severity  which 
tend  toward  a  favorable  termination  the  symptoms  should  sub- 
side in  from  one  to  three  weeks.  The  edema  gradually  passes 
away  and  the  temperature  returns  to  the  normal.  The  quantity 
of  urine  increases,  and  the  amount  of  urea  excreted,  which 
during  the  attack  has  been  much  below  the  average,  gradually 
becomes  greater,  while  the  amount  of  albumin  and  the  number 


- 

ACUTE    DIFFUSE,  ^EPHRI^tf?.  f  307 

]'r'!r-if       Cir-  / 

and  variety  of  casts  which  have  been  present'  during  the  dk-ease 
begin  to  decrease.  It  should  not  be  forgotten  that  it  is  quite 
possible  that  a  few  casts  and  a  trace  of  albumin  may  persist  for /a 
considerable  time.  The  disease,  however,  may  increase  in  severity, 
the  temperature  continue  high,  the  pulse  become  full,  rapid,  and 
of  high  tension.  The  urine,  which  before  was  scanty,  may  now 
be  actually  suppressed  and  symptoms  of  uremia  follow.  The 
attack  of  uremic  poisoning  may  begin  with  symptoms  of  restless- 
ness or  apathy,  headache,  nausea,  and  vomiting,  the  vomit  often 
having  the  odor  of  urine  ;  dimness  of  vision  is  sometimes  seen. 
Later  the  patient  may  pass  into  a  state  of  stupor  or  coma  or  have 
convulsions.  Diarrhea  is  not  an  uncommon  early  symptom  in 
children. 

Complications  and  Sequelae. — The  most  frequent  complica- 
tions are  pneumonia,  pleurisy,  edema  of  the  lung,  pericarditis,  or 
endocarditis.  Occasionally,  though  rarely,  meningitis  and  edema 
of  the  glottis  may  complicate  the  disease. 

Prognosis. — In  so  far  as  the  recovery  from  the  acute  attack 
is  concerned  the  prognosis  is  guardedly  good  ;  the  majority  of 
patients,  however,  recover.  There  is,  however,  considerable  dan- 
ger of  the  disease  progressing  into  the  chronic  form,  in  which 
the  outlook  for  absolute  recovery  is  not  so  favorable.  The  ex- 
istence of  severe  nervous  symptoms,  stupor,  intense  headache, 
dimness  of  vision,  or  the  appearance  of  uremia,  would  make  the 
outlook  less  hopeful.  The  urine  should  be  carefully  examined 
at  frequent  intervals,  as  the  amount  of  urea  and  the  number  and 
variety  of  the  casts  are  valuable  aids  in  prognosis.  Of  much  less 
importance  is  the  quantity  of  albumin  present.  Patients  suffer- 
ing from  this  disease  require  constant  watching  for  a  long  period 
of  time.  When  the  case  progresses  into  chronic  nephritis,  the 
outlook,  although  rather  doubtful  as  to  the  chances  for  absolute 
cure,  is  by  no  means  hopeless  so  far  as  the  life  and  comfort  of 
the  patient  go.  With  care  and  attention  to  diet  and  to  the  gen- 
eral rules  of  life,  many  of  these  patients  live  for  many  years. 
Relapses  are  frequent,  and  death  may  occur  during  one  of  these, 
or  the  patient  perish  from  pneumonia,  edema  of  the  lungs,  or 
from  some  intercurrent  malady. 

Treatment. — Of  primary  importance  in  the  therapeutics  of 
acute  diffuse  nephritis  is  the  stimulation  of  the  skin  as  the  most 
important  adjunct  in  eliminating  the  excrementitious  substances 
of  the  body  and  thus  aiding  the  crippled  kidneys.  For  this 
purpose  frequent  sponging  with  hot  water,  warm  baths,  or,  what 
is  often  better,  repeated  hot  packs,  are  of  the  greatest  use.  There 
may  also  be  given  sweet  spirits  of  niter,  with  or  without  very 


o»vV^-     _    \U^ 
3O8       ,  o    \D1SEASKS    OF    THE    GENITO-URINARY    SVSTEM. 

-A 

small  doses  of  ipecacuanha;  also  the  fluid  extract  of  jaborandi, 
in  doses  of  from  five  to  ten  minims,  repeated  as  often  as  may  be 
necessary  at  intervals  of  from  two  to  three  hours.  Poultices  to 
the  lumbar  region  are  most  efficacious.  The  bowels  must  be 
kept  freely  opened  by  salines  and  calomel.  These  should  be 
given  in  quantities  sufficient  to  produce  two  or  three  movements 
daily.  The  urine  should  be  diluted  as  much  as  possible  in  order 
to  decrease  its  irritating  properties.  With  this  in  view  the  patient 
should  be  made  to  drink  two  or  three  glasses  a  day  of  filtered 
water,  or,  if  it  is  preferable,  with  the  addition  of  about  twenty 
grains  of  bicarbonate  of  sodium  to  each  glass.  Some  author- 
ities recommend  that  two  or  three  grains  of  the  citrate  of  potas- 
sium be  added  to  a  glass  of  water.  The  diet  should  be  fluid, 
preferably  milk.  Should  milk  not  be  well  borne,  then  such 
preparations  as  whey,  buttermilk,  koumiss,  or  junket  may  be 
used.  If  the  nephritis  follows  an  attack  of  scarlet  fever,  it  is 
generally  recommended  that  the  patient  be  kept  in  bed  for  at 
least  a  week  after  the  temperature  has  become  normal.  In  severe 
cases,  where  the  fever  is  high,  the  urine  scanty,  and  the  amount 
of  edema  considerable,  diaphoresis  should  be  maintained  by  the 
use  of  the  hot  pack  or  vapor  bath.  Pilocarpin  may  be  used 
hypodermically,  and  be  given  in  doses  of  -£$  of  a  grain  to  a  child 
of  three  or  four  years.  In  order  to  guard  against  the  depress- 
ing effects  of  the  drug  stimulants  should  be  conjointly  given. 
One  of  the  simplest  and  at  the  same  time  a  most  effective 
method  of  producing  diaphoresis  is  to  place  under  the  bedcloth- 
ing,  at  the  feet  of  the  patient,  a  very  hot  brick,  and  upon  it  pour 
about  two  ounces  of  alcohol,  thus  producing  an  alcohol  vapor 
bath.  This  alone  will  often  bring  about  a  most  profuse  sweat- 
ing (E.  L.  Duer).  Counterirritation  should  be  applied  over  the 
kidneys  by  poultices  or  a  mustard  plaster.  In  cases  where 
symptoms  of  uremia  occur,  the  temperature  being  high,  nitro- 
glycerin  should  be  given  in  quantities  sufficient  to  produce  the 
effects  of  the  drug.  Holt  recommends  that  -%^-Q  of  a  grain  be 
given  every  hour  for  three  or  four  doses.  In  some  cases  hypo- 
dermic injections  of  morphin  may  be  of  service. 

Venesection  has  also  been  recommended  as  a  means  of  rapid 
depletion  when  the  symptoms  are  urgent.  For  the  anemia  which 
is  very  commonly  seen  iron  is  required.  When  the  disease  has 
existed  for  some  time  or  has  passed  into  the  subacute  form,  the 
patient  had  best  be  sent  to  a  warm,  dry  climate,  especially  dur- 
ing the  winter  months.  Flannel  underclothing  ought  to  be 
worn  next  the  skin,  and  every  precaution  taken  to  prevent  the 
patient  taking  cold. 


CHRONIC    NEPHRITIS.  309 

CHRONIC  NEPHRITIS. 

Under  the  title  of  chronic  nephritis  will  be  described  three 
forms  of  chronic  inflammation  of  the  kidney  structure,  both  of 
which  are  rarely  seen  in  children,  yet  occur  with  sufficient  fre- 
quency to  warrant-  at  least  passing  notice.  The  varieties  of 
chronic  nephritis  are,  first,  chronic  diffuse  nephritis  witJi  exuda- 
tion, known  also  as  chronic  parenchymatous  nephritis  or  the  large 
white  kidney  of  Bright ;  second,  the  so-called  waxy  or  lardace- 
oiis  kidney ;  third,  chronic  diffuse  nepJiritis  without  exudation, 
known  also  as  granular  kidn%,  sclerosis  of  the  kidney,  con- 
tracted kidney,  or  chronic  interstitial  nephritis. 

Causes. — The  most  frequent  cause  of  the  first  variety  is  a 
continuation  of  the  nephritis  following  an  attack  of  scarlet 
fever  or  other  disease  of  the  same  class  ;  in  fact,  the  etiology  of 
this  form  of  chronic  renal  inflammation  is  practically  the  same 
as  that  of  the  preceding  forms  described.  Waxy  kidney  is  most 
apt  to  follow  prolonged  suppuration,  especially  that  accompany- 
ing disease  of  the  bones  and  joints.  True  chronic  interstitial 
nephritis — the  variety  described  under  the  second  heading — is 
exceedingly  rare  in  childhood.  When  occurring,  the  causes 
are  generally  hereditary  syphilis,  tuberculosis,  alcoholism,  and 
chronic  valvular  diseases  of  the  heart.  Holt  states  that  in  nearly 
all  cases  the  children  suffering  from  this  are  over  seven  years 
of  age. 

Pathology. — /.  Chronic  Diffuse  Nephritis  With  Exudation. — 
Enlargement  of  the  kidneys  occurs,  the  surface  being  smooth  or 
slightly  nodular.  The  enlargement  may  be  so  great  that  the 
organ  attains  twice  the  normal  size,  and  the  capsule  can  easily 
be  separated  from  the  kidney  itself.  The  color,  not  only  of  the 
external  but  of  the  cut  surface  also,  is  yellowish  white.  Con- 
siderable tumefaction  of  the  cortex  is  found  on  section.  Micro- 
scopic examination  will  show  the  epithelium  to  be  swollen,  while 
degeneration  of  a  granular  or  fatty  character  follows.  The 
convoluted  tubes  are  dilated  and  thickened,  while  their  lumen 
contains  broken-down  granulated  epithelium  and  cast  matter. 
In  some  cases  atrophy  of  the  tubes  occurs.  The  glomeruli  will 
often  be  found  compressed  and  atrophied  from  an  excessive  for- 
mation of  new  connective  tissue.  A  fatty  degeneration  of  the 
tubular  epithelium  is  sometimes  seen. 

2.  In  the  condition  known  as  waxy  degeneration  there  is  con- 
siderable enlargement  of  the  kidneys,  the  organs  being  grayish 
in  color,  translucent,  and  glistening.  Their  consistency  is  some- 
times described  as  doughy.  Amyloid  deposits  occur  along  the 


3IO  DISEASES    OF    THE    GENITOURINARY    SYSTEM. 

renal  vessels  and  in  the  vascular  tufts  of  the  glomeruli.  This 
process  may  progress  until  the  whole  organ  is  infiltrated,  the 
true  renal  structure  undergoing  an  atrophic  degeneration.  The 
amyloid  degeneration  is  usually  associated  with  the  same  condi- 
tion in  other  organs,  especially  the  liver  and  spleen,  and  occa- 
sionally in  the  intestinal  villi.  The  situation  of  the  portions  of 
the  kidneys  affected  by  the  amyloid  change  can  be  demonstrated 
by  the  iodin  and  sulphuric  acid  reaction.  This  consists  in 
brushing  over  a  section  of  the  affected  kidney  a  solution  of  iodin 
with  iodid  of  potassium  in  water.  This  will  give  a  reaction  of  a 
mahogany  color.  If,  now,  diluted  sulphuric  acid  is  applied,  the 
color  of  the  cut  surface  will  change  to  a  bluish-violet  tint.  The 
anilin  violet  test  consists  in  brushing  over  the  kidney  a  I  per 
cent,  solution  of  anilin  violet.  That  portion  of  the  kidney  which 
has  undergone  amyloid  degeneration  will  show  a  red  or  pink 
reaction,  while  the  unchanged  tissues  are  stained  blue. 

j.  Chronic  Diffuse  Nephritis  Without  Exudation. — In  this  form 
the  kidneys  have  undergone  a  true  sclerosis  ;  the  whole  organ 
is  smaller  than  normal,  the  surfaces  being  nodular  and  the  capsule 
adherent.  Thinning  of  the  cortex  occurs,  and  the  color  is  red 
or  reddish  gray. 

The  pathologic  changes  may  be  in  part  the  same  as  those  in 
the  first  variety,  with  the  addition  of  a  great  increase  of  new 
connective-tissue  elements.  This  increase  is  distributed  in  an 
irregular  manner  throughout  the  whole  kidney  structure.  Dila- 
tation of  the  tubules  sufficient  to  form  cysts  of  varying  size  occurs 
in  places.  At  other  times  the  tubules  entirely  disappear.  Atrophy 
of  the  glomeruli  follows  unless  chronic  congestion  has  preceded 
the  inflammation.  If  chronic  congestion  has  preceded  the 
nephritis,  the  glomeruli  may  be  large  and  their  capillaries  dilated  ; 
generally,  however,  they  will  be  seen  to  have  undergone 
atrophy. 

Symptoms.  —  /.  Chronic  Nephritis  With  Exudation.  —  In 
many  cases  this  form  of  nephritis  will  not  be  recognized  until 
there  appears  a  slight  puffiness  under  the  eyes  or  occasionally 
dropsy  in  some  other  part  of  the  body.  The  patient  will  usually, 
on  examination,  be  found  to  have  had  at  some  previous  time  an 
attack  of  acute  renal  inflammation  which  has  never  entirely  sub- 
sided, but  which  has  been  unrecognized.  The  period  of  inter- 
mission since  the  original  attack  may  have  extended  for  a  vary- 
ing time  :  possibly  a  few  months  or  a  year  or  two.  In  some  cases 
the  symptoms  of  dropsy  and  anemia  follow  immediately  an  acute 
attack.  As  the  disease  progresses  various  digestive  disturbances 
are  noticed  :  there  may  be  vomiting,  not  only  after  eating,  but 


CHRONIC    NEPHRITIS.  3  I  I 

also  when  the  stomach  is  empty.  The  appetite  is  generally  les- 
sened. The  bowels  are  very  frequently  constipated,  although 
such  patients  often  have  short  attacks  of  diarrhea.  Anemia  is 
always  a  prominent  symptom.  With  each  exacerbation  of  the 
disease  various  nervous  symptoms  appear.  The  patient  will 
complain  of  violent  attacks  of  headache,  neuralgia,  sometimes 
insomnia,  and  great  loss  of  strength.  This  general  group  of 
symptoms  is  very  common,  and  appears  for  a  certain  length 
of  time,  and  then  not  infrequently  disappears  quite  suddenly, 
the  patient  in  the  interval  becoming  quite  comfortable,  gaining 
strength  to  a  certain  degree.  With  each  recurrence  the  symp- 
toms become  more  marked.  Finally  dyspnea  will  develop,  the 
heart  becomes  irritable,  vomiting  increases,  apparently  without 
cause,  and  the  patient  complains  of  vertigo  and  sometimes  of 
defects  in  vision.  The  dropsy,  which  has  previously  been  slight, 
may  extend  over  the  whole  body.  Effusions  occur  into  the 
serous  cavities,  and  the  patient  may  die  from  pulmonary  edema. 
During  the  exacerbations  of  the  disease  slight  attacks  of  epis- 
taxis  not  infrequently  occur.  During  each  onset  the  urine  is 
scanty  and  highly  colored,  containing  casts,  in  character  granu- 
lar, epithelial,  and  sometimes  fatty  or  hyaline.  Oil  globules  will 
often  be  found.  The  specific  gravity  of  the  urine  is  low,  usually 
not  over  1012  to  1015.  The  quantity  of  albumin  will  vary  con- 
siderably ;  between  the  periods  of  exacerbation  it  may  be  quite 
small  in  amount.  No  matter  how  well  the  patient  may  seem  to 
be  between  the  attacks,  some  albumin  and  some  tube-casts  are 
almost  always  present.  The  urine  will,  however,  be  passed  in 
much  larger  quantities  during  these  intervening  periods,  but  the 
specific  gravity  is  never  so  high  as  that  of  normal  urine. 

The  amount  of  urea  excreted  is  below  the  normal.  A  certain 
amount  of  vesical  irritation  is  quite  commonly  found.  The 
duration  of  this  form  of  nephritis  differs  according  to  the  sur- 
roundings of  the  patient. 

2.  Waxy  or  amyloid  degeneration  of  the  kidneys  is  usually 
accompanied  by  or  associated  with  the  same  sort  of  change  in 
other  organs,  particularly  the  liver,  spleen,  and  intestinal  canal. 
Ascites  is  a  more  marked  symptom  in  this  form.  The  urine  is 
generally  increased  in  amount,  is  yellow  in  color,  of  low  specific 
gravity,  and  will  contain  albumin  and  hyaline  casts,  and  later 
waxy  casts.  A  profuse  watery  diarrhea  is  present,  and  is  particu- 
larly marked  when  the  amyloid  changes  affect  the  intestinal 
canal,  which  makes  the  prognosis  extremely  grave.  The  pecu- 
liar whiteness  of  the  skin,  known  as  "alabaster  cachexia,"  is 
often  present. 


312  DISEASES    OF   THE    GENITOURINARY    SYSTEM. 

In  both  the  preceding  forms  of  renal  disease  death  most 
commonly  occurs  from  acute  uremia,  pneumonia,  pericarditis  or 
endocarditis,  or  from  pulmonary  edema  or  pleurisy ;  rarely, 
however,  from  uremia  in  the  amyloid, variety. 

j.  The  symptoms  of  chronic  interstitial  nephritis  in  children  are 
the  same  as  in  adults.  The  urine  is  pale  in  color  and  large  in 
quantity.  The  specific  gravity  is  low,  usually  between  1002  and 
1010.  Albumin  will  be  found  in  very  small  quantities  ;  frequently 
it  is  not  present  at  all  for  periods  of  varying  length,  as  are  also 
hyaline  casts.  Reduction  in  amount  of  urea  is  a  grave  symptom. 
Dropsy  is  rare  at  first.  On  the  other  hand,  the  arterial  tension 
is  generally  high,  and  hypertrophy  of  the  left  ventricle  is  usually 
present.  Atheroma  of  the  arteries  may  be  found  even  in  a  child 
as  young  as  six  years  of  age  (Dickinson).  Nervous  phenomena, 
such  as  headaches,  neuralgia,  various  disturbances  of  vision,  and 
dyspnea,  are  very  commonly  seen.  Death  usually  occurs  from 
acute  uremia,  although  hemorrhages,  especially  cerebral  hem- 
orrhages, may  occur  late  in  the  disease. 

The  diagnosis  of  chronic  nephritis  in  children  is  based  prac- 
tically on  the  same  facts  as  similar  disease  occurring  in  adults. 
In  cases  where  there  are  convulsions,  with  frequent  or'  persistent 
headaches,  or  such  conditions  as  anemia,  cardiac  hypertrophy, 
especially  with  high  arterial  tension,  and  in  cases  of  general 
malnutrition,  the  urine  should  be  frequently  and  carefully  ex- 
amined. When  any  of  the  group  of  symptoms  pointing  to 
renal  disease  manifest  themselves,  the  patient  should  be  kept 
under  observation  for  a  considerable  period,  and  the  case  carefully 
studied. 

Prognosis. — The  outlook  for  complete  recovery  in  any  of 
these  forms  of  nephritis  is  not  favorable.  On  the  other  hand, 
much  can  be  done  in  the  first  variety  for  the  comfort  of  patients 
and  the  prolongation  of  their  lives.  There  is  no  doubt  that  many 
cases  affected  with  chronic  nephritis,  especially  the  exudative 
variety,  live  for  years,  providing  they  are  placed  amid  comfortable 
surroundings,  are  kept  absolutely  free  from  worry,  and  in  a 
climate  of  reasonably  equable  temperature,  particularly  one  free 
from  extremes  of  cold  and  heat.  The  prognosis  in  cases  of  waxy 
kidney  is  about  the  same  as  in  the  preceding  form.  It  is  possible 
that  recovery  may  take  place  when,  in  cases  resulting  from  pro- 
longed suppuration  of  bone,  the  diseased  structure  has  been 
removed.  The  prognosis  in  the  interstitial  variety  of  nephritis  is 
always  bad,  although  the  progress  of  the  disease  is  generally 
quite  slow.  The  immediate  prognosis  will  depend  considerably 
on  the  amount  of  dropsy,  the  existence  of  valvular  disease  of  the 


CHRONIC    NEPHRITIS.  313 

heart,  the  amount  of  urea  excreted,  and  the  strength  of  the  gen- 
eral excretory  power  of  the  kidneys. 

Treatment. — Children  affected  with  chronic  nephritis  should 
be  placed  amid  surroundings  free  from  nervous  worry  and  strain 
of  all  kinds.  It  is  very  important  that  such  children,  as  soon  as 
the  disease  is  recognized,  be  kept  from  school,  or  at  least  from 
hard  study.  If  possible,  they  should  be  sent  to  a  dry,  warm 
climate,  especially  during  the  winter  months.  Great  care  should 
be  exercised  that  these  patients  do  not  take  cold.  Woolen  under- 
clothing should  be  worn  next  to  the  skin  at  all  seasons  of  the 
year.  While  overfatigue  is  extremely  dangerous,  yet  regular  ex- 
ercise in  the  open  air  is  of  the  greatest  benefit.  They  should 
be  dressed  warmly  in  winter,  and  in  summer  their  clothing  should 
be  so  regulated  as  to  allow  them  as  much  coolness  as  possible, 
yet  avoiding  any  danger  of  chilling.  The  general  aim  of  the 
treatment  is  to  retard  the  progress  of  the  disease  as  much  as 
possible,  and  when  symptoms  arrive,  to  relieve  them.  Tonics  are 
nearly  always  indicated.  A  good  rule  to  remember  in  the  admin- 
istration of  remedies  to  these  patients  is  that  during  the  periods 
of  quiescence  of  the  disease  as  little  medicine  should  be  given  as 
possible.  While  milk  is  in  many  respects  the  best  article  of  diet, 
yet  frequently  it  can  not  be  borne  for  a  long  period  of  time  ;  it 
becomes  extremely  disgusting  to  some  patients,  and  will  finally 
do  more  harm  than  good.  Sometimes,  when  milk  can  not  be 
taken  by  itself,  it  can  be  used  on  desserts,  on  fruit,  or  given  in  some 
other  way  to  make  it  more  palatable.  Much  meat  must  not  be 
allowed,  especially  where  there  is  a  tendency  to  a  diminution  in 
the  excretion  of  urea,  and  salt  meats  should  be  prohibited.  The 
lighter  soups,  fresh  fish,  oysters,  and  foods  of  this  description 
may  be  given  in  moderation,  as  also  may  farinaceous  foods  and 
the  starchy  vegetables.  The  patient  should  be  encouraged  to 
drink  water,  and  for  this  purpose  many  of  the  mineral  waters  are 
recommended,  not  so  much  for  their  own  inherent  qualities  as  on 
account  of  their  being  more  palatable. 

Iron  should  be  prescribed  when  anemia  is  a  prominent 
symptom,  and  when  considerable  dropsy  exists,  diuretics,  saline 
laxatives,  and  calomel  in  small  doses  are  needed.  When  the 
heart  is  weak,  this  condition  will  naturally  call  for  cardiac  stim- 
ulants. The  skin  should  be  made  to  do  as  much  work  as  pos- 
sible, thereby  easing  the  crippled  kidneys,  and  with  this  in  view 
sponge-baths  of  hot  water  or  occasional  vapor  baths  are  useful. 
Attacks  of  uremia  should  be  treated  in  the  usual  way.  If  the 
arterial  tension  is  high  and  there  are  convulsions  or  stupor, 
blood-letting  may  be  resorted  to.  In  many  of  these  cases  nitro- 


314  DISEASES    OF    THE    GENITOURINARY    SYSTEM. 

glycerin  will  also  be  found  useful.  The  hot  pack  and  the  alco- 
hol vapor  bath  before  alluded  to  are  probably  the  best  means  of 
producing  rapid  diaphoresis.  In  cases  where  the  uremic  con- 
vulsions are  marked  and  are  accompanied  by  dilatation  of  the 
pupil,  morphin  may  be  administered  hypodermically. 

PERINEPHRITIS. 

Definition. — Perinephritis  consists  of  an  inflammation  of  the 
connective  tissue  surrounding  the  kidney. 

Causes. — In  origin  it  may  be  primary  or  secondary.  If 
primary,  the  cause  may  be  from  cold  or  exposure  or  traumatism. 
Occasionally  it  develops  without  any  known  cause.  Secondary 
perinephritis  may  follow  suppurative  diseases  of  the  kidney,  a 
perforative  appendicitis,  or  even  caries  of  the  vertebrae. 

Pathology. — The  perinephric  tissues  of  both  kidneys  are 
affected  with  equal  frequency,  and  the  disease  is  as  common  in 
girls  as  in  boys.  It  may  be  found  at  any  age.  When  the  in- 
flammatory process  progresses  to  the  formation  of  an  abscess, 
the  latter  usually  burrows  between  the  lumbar  muscles,  and 
may  appear  superficially  in  the  posterior  part  of  the  body,  near 
the  middle  of  the  ileocostal  space.  Sometimes  it  may  proceed 
between  the  abdominal  muscles  and  point  above  Poupart's 
ligament.  Occasionally  it  may  appear  at  the  upper  and  inner 
aspect  of  the  thigh,  or  it  may  rupture  into  the  peritoneal  cavity, 
vagina,  or  bladder. 

Symptoms. — The  symptoms  of  perinephritis  are  those  of 
acute  inflammation.  The  attack  usually  begins  with  a  chill, 
fever,  and  pain.  The  pain  is  usually  felt  in  the  lumbar  region, 
in  the  groin,  along  the  inner  side  of  the  thigh,  and  in  the  knee, 
and  is  generally  increased  on  moving  the  leg.  When  the  disease 
has  existed  for  some  time,  a  distinct  tumor,  accompanied  by 
tenderness,  may  be  seen  and  felt  over  the  region  of  the  kidney 
on  the  affected  side,  and  this  tenderness  may  extend  to  the  hip 
or  along  the  back.  As  the  inflammation  proceeds  there  may 
be  stiffness  in  the  hip  on  the  affected  side.  The  thigh  is  flexed 
and  extension  will  cause  resistance  and  pain.  Other  movements 
of  the  limb,  however,  are  normal.  Symptoms  referable  to  the 
kidneys  themselves  are  not  present  in  all  cases.  Their  presence 
will  depend,  to  a  certain  extent,  on  whether  or  not  these  organs 
share  in  the  inflammation.  Sometimes  there  may  be  some  pain 
on  micturition,  and  this  may  be  increased  in  frequency.  When 
pyelitis  exists,  the  urine  will  contain  pus.  The  disease  may  vary 
greatly  as  to  the  length  of  its  duration.  Acute  cases  may  run 


PYELITIS.  3  I  5 

a  course  of  from  four  to  eight  weeks.  The  disease  may,  how- 
ever, last  for  several  months. 

Diagnosis. — The  disease  with  which  perinephritis  is  most 
likely  to  be  confounded  is  inflammation  of  the  Jiip-joint.  The 
two  affections,  however,  have  distinct  points  of  difference  which 
will  make  the  diagnosis  one  of  not  great  difficulty.  Perinephritis 
is  a  disease  of  much  more  intense  and  rapid  onset,  and  the 
general  symptoms  are  those  of  an  acute  inflammation  ;  whereas 
in  hip-joint  disease  the  condition  develops  slowly  and  the  consti- 
tutional symptoms  may  be  wholly  absent  during  the  early  stages 
of  the  affection.  In  perinephritis  there  is  interference  with  flexion 
and  extension  of  the  thigh,  but  the  other  motions  are  not  inter- 
fered with ;  whereas  in  hip-joint  disease  all  movements  of  the 
joint  are  restricted,  and  there  is  also  tenderness  in  the  joint  itself. 
The  characteristic  secondary  changes  in  the  thigh  which  are 
always  present  in  hip-joint  disease  are  absent  in  perinephritis. 
Psoas  abscess  may  be  mistaken  for  perinephritis,  but  in  the  former 
we  usually  have  present  the  symptoms  of  tubercular  disease,  its 
characteristic  temperature,  and  very  possibly  some  deformity  of 
the  spine  may  be  seen  to  aid  in  the  diagnosis. 

Prognosis  is  fairly  good.  The  majority  of  cases  recover 
from  this  disease. 

Treatment. — This  should  consist  in  complete  rest,  and  when 
the  case  is  seen  early,  counterirritation  should  be  applied  over  the 
lumbar  region,  or,  in  some  cases,  an  ice-bag  may  give  a  better 
result  than  heat.  Poultices  sometimes  give  relief.  As  soon  as 
the  presence  of  pus  can  be  demonstrated,  an  incision  should  be 
made  and  free  drainage  established. 


PYELITIS. 

Pyelitis  is  an  inflammation  of  the  mucous  membrane  lining 
the  pelvis  of  the  kidney.  When  a  portion  of  the  ureter  or  of 
the  true  kidney  structure  is  involved,  the  condition  is  known 
as  pyelonephritis.  When  an  accumulation  of  pus  exists  in 
the  pelvis  of  the  kidney,  the  condition  is  known  as  pyoneph- 
rosis. 

Causes. — The  condition  may  arise  from  congenital  malforma- 
tions of  the  kidneys  or  ureters,  from  tuberculosis,  or  from  new 
growths.  It  may  also  be  caused  by  an  extension  of  an  inflam- 
mation of  the  surrounding  tissues.  Extension  upward  of  a  septic 
inflammation  of  the  genito-urinary  tract  is  a  very  common  cause. 
It  not  infrequently  arises  from  an  irritation  produced  by  a  renal 
calculus.  An  acute  form  of  the  disease  may  follow  an  attack 


316  DISEASES    OF    THE    GENITO-URINARY    SYSTEM. 

of  the  infectious  fevers  or  of  septicemia.  Not  infrequently  neph- 
ritis is  coexistent. 

Pathology. — Pyelitis  may  affect  one  or  both  kidneys.  In  the 
acute  form  the  mucous  membrane  presents  the  usual  appearance 
of  acute  catarrhal  inflammation  ;  it  is  congested,  swollen,  and,  in 
the  severer  cases,  with  formation  of  pus,  small  hemorrhages  will 
be  found.  When  the  disease  becomes  chronic,  the  mucous 
membrane  is  thickened  and  granular. 

Symptoms. — The  symptoms  will,  to  a  certain  extent,  depend 
upon  the  cause.  When  the  attack  is  acute  and  is  produced  by 
a  stone  or  other  cause  of  direct  renal  irritation,  there  may  be 
chills,  pain,  fever,  and  attacks  of  renal  colic.  When  the  cause  is 
tuberculosis  or  abscess  in  the  kidney,  there  will  be  recurring 
chills,  fever,  sweats,  and  some  pain.  The  patient  will  suffer  pro- 
gressive loss  of  flesh,  and  present  the  general  appearance  of 
deteriorated  health.  The  quantity  of  urine  is  usually  somewhat 
diminished.  Its  reaction  is  acid  ;  albumin,  pus,  and  epithelial 
and  blood-cells  are  found  in  it.  Hyaline  and  granular  epi- 
thelial casts  and  bacteria  are  also  generally  present. 

The  diagnosis  can  be  made  from  the  symptoms  and  from 
examination  of  the  urine.  In  differentiating  this  condition  from 
cystitis  it  should  be  remembered  that  the  urine  is  less  apt  to  be 
acid  in  reaction  in  inflammation  of  the  bladder,  and  in  the  latter 
condition  the  quantity  of  pus  will  be  much  less.  The  presence 
of  tube-casts  and  of  renal  epithelial  cells,  as  well  as  the  more 
severe  general  symptoms,  will  generally  be  sufficient  to  prove 
the  diagnosis. 

Treatment. — The  patient  should  be  placed  on  a  fluid  diet, 
and  when  the  urine  is  irritating,  by  reason  of  its  high  degree  of 
acidity,  the  latter  should  be  neutralized  by  the  administration  of 
citrate  of  potassium  or  by  free  administration  of  a  simple  alkaline 
water.  Counterirritation  over  the  lumbar  region  by  the  use  of 
dry  cups,  poultices,  or  mustard  plasters  should  be  employed. 
When  pyonephrosis  exists,  the  question  of  surgical  interference 
must  be  considered.  If  only  one  kidney  is  affected,  its  removal 
promises  a  chance  of  recovery  ;  but  usually  both  organs  are 
involved. 

RENAL  CALCULI. 

Renal  calculi  may  be  formed  at  any  period  of  life.  The  stones 
may  vary  in  size  very  considerably.  They  are  usually  found  in 
the  pelvis  and  calices  of  the  kidney  and  are  composed  of  uric 
acid.  When  very  small,  they  may  be  seen  as  small  granular 
deposits  in  the  pelvis  of  the  kidney. 


TUBERCULOSIS    OF    THE    KIDNEY.  317 

Symptoms. — When  the  deposits  are  small,  they  may  be  ex- 
creted through  the  pelvis  of  the  kidney  and  ureter  without 
producing  any  symptoms.  When  large,  however,  their  passage 
generally  causes  the  condition  known  as  renal  colic.  The  patient 
is  suddenly  seized  with  intense  pain  and  tenderness  over  the 
affected  kidney.  The  pain  soon  radiates  around  the  affected 
side  diagonally  across  the  abdomen  to  the  region  of  the  bladder. 
There  may  be  pain  in  the  perineum,  and  in  boys  the  testicle  on 
the  affected  side  is  retracted.  Sometimes  the  pain  may  even 
radiate  to  the  opposite  side  of  the  body.  The  attack  will  con- 
tinue at  intervals  until  the  stone  has  reached  the  bladder,  when 
it  usually  ceases  suddenly.  During  the  attack,  and  for  a  short 
time  afterward,  the  urine  may  contain  traces  of  blood  and  some 
albumin.  When  pyelitis  has  been  produced  by  the  irritation  of 
the  stone,  the  symptoms  of  this  condition  will  be  present,  and 
the  urine  will  contain  pus  and  epithelial  cells  from  the  pelvis  of 
the  kidney.  In  some  cases  the  pain  is  so  great  as  to  produce 
collapse.  When  the  stone  becomes  impacted  in  the  upper  part 
of  the  ureter,  hydronephrosis  or  pyonephrosis  occurs. 

The  treatment  of  renal  calculi  in  children  is  the  same  as  in 
the  adult 

TUBERCULOSIS   OF   THE   KIDNEY. 

Tubercular  affection  of  the  kidney  usually  occurs  as  a  second- 
ary complication  of  general  tubercular  disease.  The  source  of 
infection  is  often  in  the  blood,  and  very  rarely  the  extension 
of  tubercular  disease  from  the  bladder.  It  is  stated  that  the  dis- 
ease generally  begins  in  the  pelvis  and  calices  of  the  kidney. 
Later  the  pyramids  and  cortex  become  involved.  As  a  rule,  only 
one  of  the  kidneys  is  affected.  Not  infrequently  a  tubercular 
perinephric  abscess  will  coexist. 

Symptoms. — These,  in  many  cases,  are  obscure.  Pain  or 
tenderness  in  the  region  of  the  kidney  and  possibly  some  swell- 
ing are  common  features  ;  the  latter  is  particularly  the  case  if 
perinephritis  exists.  Irritability  of  the  bladder  is  generally  pres- 
ent. The  urine  is  decreased  in  amount  and  contains  pus.  A 
sure  point  of  diagnosis  would  be  the  recognition  of  the  tubercle 
bacillus  in  the  urine.  Renal  tuberculosis  is  most  commonly 
seen  in  children  between  two  and  twelve  years  of  age,  although 
it  may  be  found  at  any  period  of  life. 

The  treatment  is  purely  surgical,  and  consists  in  removing 
the  kidney. 


318  DISEASES    OF    THE    GENITOURINARY    SYSTEM. 


TUMORS   OF   THE   KIDNEY. 

Tumors  of  the  kidney  in  childhood  may  be  benign  or  malig- 
nant. The  former  are  very  rare.  Aldibert  has  reported  three 
cases  :  one  each  of  adenoma,  fibroma,  and  fibrocystic  tumor. 
These  tumors  can  be  recognized  by  their  slow  growth  and  by 
their  mild  constitutional  symptoms.  The  commonest  forms  of 
malignant  tumors  of  the  kidney  occurring  in  children  are  sarcoma 
and  carcinoma,  the  former  being  most  frequently  seen.  They 
are  usually  primary  growths,  and  rarely  occur  in  children  under 
five  years  of  age.  After  this  time,  however,  they  are  by  no 
means  a  rare  form  of  abdominal  neoplasm. 

Pathology. — The  type  of  sarcoma  is  usually  round-  or  spindle- 
celled,  but  myosarcoma  is  sometimes  seen.  They  may  grow 
from  the  cortex  or  the  pelvis  of  the  kidney,  and  sometimes  from 
the  adrenals.  Infiltration  of  the  whole  organ  may  take  place 
even  to  such  an  extent  as  to  destroy  the  entire  renal  structure. 
Metastasis  may  occur  in  the  opposite  kidney,  lungs,  or  other 
neighboring  structures.  Hydronephrosis,  due  to  pressure  upon 
the  ureter,  or  serious  complications,  such  as  thrombosis,  from 
pressure  upon  the  vena  cava,  may  take  place.  As  the  tumor 
grows  it  becomes  adherent  to  the  surrounding  organs.  Ascites 
and  general  peritonitis  may  appear  in  the  later  stages.  In  size 
the  tumor  may  reach  very  considerable  proportions.  Accord- 
ing to  Holt,  the  weight  may  be  as  high  as  fifteen  pounds,  and  he 
states  that  one  case  has  been  reported  by  Jacobi  in  which  the 
tumor  weighed  thirty-six  pounds.  The  right  kidney  is  rather 
more  frequently  involved  than  the  left. 

Symptoms. — The  principal  symptoms  are  a  rapidly  growing 
tumor,  with  progressive  emaciation  and  cachexia.  Pain  may  be 
present,  but  not  infrequently  it  is  slight  or  may  be  entirely  absent. 
The  tumor  may  at  times  be  made  out  over  the  region  of  the 
kidney,  but  oftener,  as  it  grows  in  the  direction  of  least  resis- 
tance, is  felt  underlying  the  large  bowel.  The  increase  in  size  is 
rapid.  The  urine  may  at  intervals  contain  blood,  pus,  or  albumin. 
Sometimes  this  does  not  occur  until  late  in  the  disease. 

The  prognosis  is  unfavorable. 

The  treatment  should  be  by  operative  means. 


The  uric  acid  conditions  (lithuria,  lithemid)  are  considered  in  the 
chapter  on  Constitutional  Diseases,  page  389. 


CHAPTER  IX. 

DISEASES  OF  THE  GENITAL  ORGANS. 


ADHERENT  PREPUCE  AND  PHIMOSIS. 

Adhesions  between  the  prepuce  and  the  glans  penis  are  not 
infrequent  at  birth.  They  may  appear  in  congenital  forms  or 
may  be  acquired.  If  the  latter,  they  are  usually  caused  by  an 
irritation  set  up  by  the  collection  of  smegma  accumulating  under 
a  long,  tight  foreskin.  Phimosis  is  that  condition  by  which  the 
foreskin  is  prevented  from  being  drawn  back  over  the  glans 
by  an  abnormal  smallness  of  the  opening  of  the  prepuce. 
Both  adherent  prepuce  and  phimosis  of  a  not  marked  degree 
are  seen  in  a  large  number  of  children,  and  both  conditions 
frequently  disappear  shortly  after  birth.  They  may,  however, 
give  rise  to  quite  a  variety  of  very  distressing  symptoms  and 
sequelae.  Thus  we  may  have  great  pain  on  urination,  which 
will  cause  the  infant  to  cry  vehemently,  and  in  many  of  these 
cases  it  will  be  seen  that  the  foreskin  will  balloon  during  the  act 
of  urination,  showing  that  the  prepuce  is  adherent  to  the  glans, 
the  stream  of  urine  being  very  small,  or  in  some  cases  simply 
dropping  away.  A  certain  amount  of  urine  is  generally  retained 
and  will  increase  the  irritation — in  fact,  may  set  up  an  actual 
balanitis  or  even  a  cystitis.  Various  nervous  phenomena  may 
accompany  the  condition.  In  infants  as  well  as  older  children 
the  symptoms  may  be  very  varied.  Choreic  movements,  incon- 
tinence of  urine,  convulsions,  and  persistent  spasm  of  certain  sets 
of  muscles  may  be  produced,  and  a  chronic  state  of  malnutrition 
often  follows  this  condition.  There  may  be  even  a  prolapse  of  the 
rectum,  or  hernia  from  constant  straining  in  voiding  the  urine. 
Adherent  prepuce  and  phimosis  are  undoubtedly  among  the 
most  common  causes  of  masturbation  in  young  boys. 

The  treatment  should  consist  in  breaking  up  the  adhesions 
by  passing  the  end  of  a  blunt  probe  between  the  mucous  mem- 
brane and  the  glans  and  dilating  the  preputial  orifice  with  the 
blades  of  a  pair  of  surgical  dressing  forceps.  After  this  is  done 
the  prepuce  should  be  drawn  back  so  as  to  expose  the  glans, 

319 


32O  DISEASES    OF    THE    GENITAL    ORGANS. 

which  should  then  be  cleansed  and  anointed  with  vaselin  or  any 
bland  antiseptic  ointment,  after  which  the  prepuce  should  be 
brought  forward  again.  This  should  be  done  gently  and  repeated 
every  day  until  danger  of  readhesion  be  passed.  It  is  our  ex- 
perience— and  we  habitually  give  attention  to  the  condition  of  the 
foreskin  in  all  male  babies — that  the  careful  and  prompt  operation 
of  stripping  is  in  the  majority  of  cases  sufficient.  The  need_for 
the  operation  of  circumcision  is  much  exaggerated.  It  should  be 
borne  in  mind  that  where  the  foreskin  is  kept  back  too  long  there 
is  some  danger  of  producing  the  condition  known  as  para- 
phimosis.  Where  dilatation  does  not  produce  relief  after  several 
repetitions,  the  foreskin  may  be  slit  up  as  far  as  the  corona 
glandis,  along  the  dorsum,  and  the  edges  trimmed  off  with  a 
pair  of  scissors.  The  mucous  membrane  may  be  stitched  to  the 
skin  with  fine  silk  or  fine  catgut.  If  this  does  not  give  relief, 
the  regular  operation  of  circumcision  should  be  performed. 

PARAPHIMOSIS. 

Paraphimosis  is  a  condition  in  which  the  prepuce  has  been  drawn 
back  over  the  corona  glandis,  and  by  reason  of  an  abnormally 
small  preputial  orifice  or  an  increased  size  of  the  glans,  can  not 
be  returned  to  its  proper  position.  Following  the  retraction  of 
the  prepuce  there  are  usually  swelling  of  the  glans  and  consid- 
erable edema.  It  may  occur  from  a  variety  of  causes.  It  may 
be  congenital,  although  this  form  is  rare. 

The  treatment  consists  in  endeavoring  to  reduce  the  para- 
phimosis  as  quickly  as  possible  by  pressing  the  glans  with  the 
thumb  and  finger  of  one  hand,  while  with  the  other  hand  an 
effort  is  made  to  draw  the  foreskin  forward  over  the  corona. 
Where  this  fails,  it  may  be  necessary  in  some  cases  to  make  a 
series  of  small  punctures  of  the  edematous  mucous  membrane, 
after  which  the  same  manipulation  should  be  repeated.  If  the 
second  method  is  not  successful,  the  end  of  a  blunt-pointed  bis- 
toury should  be  introduced  under  the  edge  of  the  prepuce  which 
forms  the  constricting  ring,  and  severing  it  on  the  dorsum  of  the 
glans.  It  may  be  necessary  to  divide  the  ring  at  more  than 
one  point.  The  local  injection  of  cocain,  the  part  having  been 
previously  anesthetized  with  chlorid  of  ethyl  or  ice  and  salt,  is 
often  all  that  is  necessary,  but  occasionally  etherization  of  the 
patient  will  be  required  before  operating.  Circumcision  should 
not  be  resorted  to  unless  necessary. 


BALANITIS VULVOVAGINITIS.  321 

BALANITIS. 

This  condition  is  occasionally  met  with  in  children,  and  is 
frequently  the  result  of  neglected  phimosis.  Very  considerable 
swelling  of  the  prepuce  occurs,  accompanied  by  discharge,  often 
of  large  quantities  of  pus,  producing  great  pain  and  scalding  on 
micturition. 

The  treatment  should  consist  in  syringing  the  cavity  beneath 
the  prepuce  with  a  warm,  bland  antiseptic  solution.  After  relief 
of  the  phimosis,  application  of  lead-water  will  often  reduce  the 
inflammation. 

VULVOVAGINITIS. 

Vulvovaginitis  in  children  is  usually  found  in  two  forms,  the 
catarrhal  and  the  gonorrheal.  The  catarrhal  form  arises  from 
irritation,  which  is  produced  by  a  variety  of  causes.  In  very 
young  children  it  may  be  brought  about  by  the  continued  use 
of  diapers  soiled  with  discharges  or  from  general  lack  of  clean- 
liness. Seat-worms  are  a  very  common  cause.  It  may  also  be 
due  to  traumatism  and  attempts  at  rape,  or,  in  rare  cases,  a  true 
gonorrheal  infection.  A  form  of  vulvovaginitis  known  as  the 
aphthous  variety  is  found  in  generally  ill-nourished  and  unhealthy 
children,  or  may  occur  as  a  sequela  of  one  of  the  continued 
fevers  or  any  constitutional  disease,  as  nephritis,  tuberculosis,  etc. 

In  girls  at  the  age  of  puberty  it  sometimes  arises  from  reten- 
tion of  the  menstrual  secretion  by  an  imperforate  hymen. 

The  symptoms  are  those  found  in  other  forms  of  catarrhal 
inflammation.  There  are,  generally,  discomfort,  some  swelling 
of  the  parts,  a  burning  pain  on  micturition,  and  a  local  rise  of 
temperature.  The  secretion  is  at  first  arrested,  the  parts  becom- 
ing dry,  but  later  it  is  considerably  increased,  often  with  forma- 
tion of  pus.  The  patient  complains,  as  a  rule,  of  continual 
smarting  and  burning.  There  may  be,  in  the  early  stages,  some 
general  rise  of  temperature. 

In  the  gonorrheal  form  the  symptoms  are  the  same  as  in  the 
previous  variety,  except  that  they  are  apt  to  be  more  intense.  The 
discharge  is  free,  and  consists  of  thick,  greenish-yellow  pus,  in 
which  gonococci  can  be  found.  The  parts  are  excoriated,  and 
generally  very  painful.  Some  swelling  of  the  inguinal  glands 
may  occur.  It  is  by  no  means  uncommon  in  children,  as  in 
adults,  to  find  the  urethra  involved  in  the  general  irritation.  A 
positive  differential  diagnosis,  however,  can  not  always  be  made 
without  the  aid  of  the  microscope  and  culture  tube. 

The  prognosis  in  both  forms  of  vulvovaginitis  is  good.    How- 


322  DISEASES    OF    THE    GENITAL    ORGANS. 

ever,  it  must  be  borne  in  mind  that  in  the  gonorrheal  form  the 
infection  may  spread  into  the  urethra  and  bladder,  producing 
inflammation  of  these  parts. 

The  treatment  consists  of  absolute  cleanliness.  The  parts 
should  be  bathed  in  warm  water  and  Castile  soap,  after  which 
they  may  be  dusted  with  a  powder  consisting  of  calomel  and 
starch,  bismuth  and  starch,  or  boric  powder.  Ichthyol,  in  the 
proportion  of  5  parts  to  100  of  glycerin,  may  be  applied  on  a 
tampon,  or  pledgets  of  cotton  saturated  in  lead-water  and  lauda- 
num may  be  used.  Where  the  irritation  is  caused  by  worms, 
rectal  injections  of  an  infusion  of  quassia  in  the  strength  of  one 
to  two  ounces  to  a  pint  of  water  may  be  used  with  benefit.  The 
aphthous  form  should  be  treated  not  only  by  local  applications, 
but  also  by  attention  to  the  general  health,  efforts  being  made  to 
build  the  patient  up,  so  far  as  possible,  by  tonics  and  nutritious 
food. 

Gonorrheal  vulvovaginitis  is  best  treated  by  local  applications 
of  corrosive  sublimate,  I  :  5000  ;  boric  acid,  one  dram  to  one 
pint ;  creolin,  i  :  500,  or,  in  some  cases,  a  2  per  cent,  solution  of 
nitrate  of  silver.  These  should  be  applied  by  means  of  pledgets 
of  cotton  placed  between  the  labia,  or  may  be  injected  in  the  va- 
gina by  means  of  a  small  rubber  catheter  attached  to  a  fountain 
syringe.  Before  applying  any  of  the  above,  it  is  generally  well  to 
wash  the  parts  thoroughly  with  warm  water  and  Castile  soap, 
after  which  they  should  be  carefully  dried  by  means  of  pieces  of 
absorbent  cotton.  The  parts  may  be  dusted  with  a  powder  con- 
sisting of  bismuth  and  starch  or  pulverized  oxid  of  zinc  and 
boric  acid. 

ORCHITIS. 

Inflammation  of  the  testis  is  seldom  seen  in  childhood,  except 
as  the  result  of  traumatism.  It  may  rarely  follow  an  attack  of 
mumps,  but  in  childhood  this  is  much  less  frequent  than  in  the 
adult.  Not  infrequently  orchitis  is  accompanied  by  hydrocele. 

The  treatment  should  consist  in  supporting  the  testicle  by 
means  of  a  suitable  bandage  or  pads  of  cotton  and  the  local 
application  of  lead-water  and  laudanum.  Laxatives  should  be 
used  to  keep  the  bowels  freely  opened. 


TUBERCULAR  DISEASE  OF  THE  TESTICLE. 

Tubercular  disease  of  the  testicle  is  rarer  in  infancy  and  child- 
hood than  in  adult  life.  When  present,  the  testicle  will  be  found 
considerably  swollen,  nodular,  and  not  very  tender.  As  the  dis- 


EPIDIDYMITIS HYDROCELE.  323 

ease  progresses  adhesions  may  form  between  the  testicle  and  the 
scrotum.  The  glands  may  break  down  late  in  the  disease  and 
suppuration  occur.  Tubercular  disease  of  the  testicle  is  found 
in  two  forms  :  (i)  As  secondary  to  a  general  tubercular  infec- 
tion or  (2)  as  a  part  of  a  localized  tuberculosis  of  the  genito- 
urinary tract. 

Treatment. — Where  the  diseased  condition  of  the  testicles  is 
a  part  of  a  general  tuberculosis,  the  orchitis  should  be  treated 
symptomatically  and  attention  paid  to  the  general  tubercular 
infection,  the  treatment  of  which  is  considered  in  the  chapter  on 
Tuberculosis.  In  all  cases  of  tubercular  disease  of  the  testes 
castration  should  be  performed  ;  especially  should  this  be  done 
to  young  children.  There  is  always  a  danger  of  general  sys- 
temic infection  resulting  from  the  diseased  testicle. 


EPIDIDYMITIS. 

Inflammation  of  the  epididymis  may  be  caused  by  traumatism 
or  by  continuation  of  irritation  of  the  urethral  mucous  mem- 
brane. The  epididymis  will  be  found  considerably  enlarged  and 
very  tender,  and  by  its  swelling  it  will  push  the  testicle  forward. 
The  spermatic  cord  is  often  inflamed,  enlarged,  and  extremely 
painful  on  pressure.  It  is  not  uncommon  to  find  the  whole  scro- 
tum swollen  and  very  painful. 

The  treatment  should  consist  of  absolute  rest,  the  patient 
lying  on  his  back.  The  bowels  should  be  kept  open.  Local 
applications  in  the  form  of  hot  poultices  or  lead-water  and  laud- 
anum should  be  made  to  the  scrotum.  The  scrotum  should 
always  be  supported  in  this  as  in  all  forms  of  inflammation  of  this 
region.  Rotch  recommends  that  the  testicle  be  always  placed  in 
such  a  position  that  the  lower  end  of  the  gland  points  upward. 


HYDROCELE. 

This  condition  is  not  at  all  uncommon  in  children,  being  quite 
frequently  met  with  in  the  early  years  of  life,  and  may  be  acute 
or  chronic.  It  may  result  from  a  variety  of  causes,  sometimes 
arising  from  traumatism,  as  by  pressure,  and  sometimes  during 
or  after  attacks  of  influenza,  typhoid  fever,  scarlatina,  or  mumps. 
It  may  in  some  instances  result  from  simple  irritation.  Occasion- 
ally it  is  congenital.  The  form  known  as  infantile  hydrocele  is 
really  a  condition  where  the  tunica  vaginalis  and  funicular  pro- 
cess are  distended  with  fluid,  the  processes  being  closed  at  the 


324  DISEASES    OF    THE    GENITAL    ORGANS. 

internal  abdominal  ring.  The  funicular  part  of  the  process  may 
remain  open  and  be  shut  off  from  the  tunica  vaginalis. 

In  the  third  variety  there  may  be  an  encysted  hydrocele  of 
the  cord,  due  to  distention  of  an  unclosed  segment  of  the  funic- 
ular process. 

Diagnosis. — The  condition  with  which  it  is  most  likely  to  be 
confused  is  scrotal  hernia,  the  diagnosis  of  which  has  been  given 
under  the  head  of  Hernia. 

Treatment. — In  acute  hydrocele  rest  and  the  local  application 
of  cold,  ichthyol,  or  lead-water  cloths  are  employed,  or  treat- 
ment by  puncture  if  the  above  be  unsuccessful.  Chronic  cases 
should  be  treated  by  a  truss  in  the  same  manner  as  hernia,  an 
effort  being  made  to  close  the  neck  of  the  canal. 

In  all  forms  of  irreducible  hydrocele  the  treatment  is  by  evac- 
uation of  the  fluid  by  means  of  a  small  trocar  and  cannula  under 
antiseptic  precautions.  If  this  is  unsuccessful,  it  is  advisable  that 
the  sac  be  extirpated  or  a  weak  solution  of  iodin  be  injected. 
When  a  cure  is  not  effected  by  means  of  simple  evacuation,  the 
sac  should  be  laid  open,  the  cavity  packed  with  iodoform  gauze, 
the  strictest  antiseptic  precautions  being  followed,  and  the  wound 
allowed  to  heal  by  granulation.  If  the  sac  be  large,  a  small 
portion  of  its  walls  on  each  side  of  the  incision  should  be  cut 
away.  This  is  a  perfectly  safe  and  rapid  method  of  radical  cure 
of  this  condition.  Many  cases  of  the  infantile  variety  get  well 
without  treatment. 

Hydrocele  in  Female  Children. — Although  hydrocele  is 
much  rarer  in  female  than  in  male  children,  yet  it  sometimes 
occurs.  It  consists  in  a  collection  of  fluid  in  the  tube-like  pouch 
of  the  peritoneum,  which  accompanies  the  round  ligament  through 
the  inguinal  canal  and  is  known  by  the  name  of  the  canal  of 
Nuck.  Occasionally  the  exudation  of  fluid  may  take  place  in 
the  tissues  of  the  round  ligament  itself  or  in  the  labium  majora, 
external  to  the  covering  of  the  round  ligament. 

The  symptoms  will  be  the  appearance  of  a  tumor  in  the  labia 
or  in  the  inguinal  region.  Fluctuation  will  be  obtained  in  this 
tumor.  It  will  also  be  translucent.  Appearing  in  girls  at  the 
age  of  puberty,  it  might  possibly  be  confounded!  with  a  cyst  or 
abscess  of  the  vulvovaginal  gland,  but  the  lack  of  inflammatory 
symptoms  and  the  fact  that  cysts  are  found  in  the  upper  and 
outer  part  of  the  labii  majorae  would  aid  in  the  diagnosis. 
Pudendal  hernia  would  be  excluded  by  the  fact  that  in  hydrocele 
there  is  no  impulse  on  coughing  and  the  other  symptoms  of 
hernia  are  absent. 

The  treatment  is  the  same  as  that  of  hydrocele  in  male  chil- 
dren. 


UNDESCENDED    TESTICLE HYPOSPADIAS.  325 

VARICOCELE  is  a  very  rare  affection  in  childhood.  Ashby  and 
Wright  claim  they  have  never  seen  it  earlier  than  the  tenth 
year. 

Treatment  will  be  the  same  as  that  for  the  same  affection  in 
adults. 

OVARIAN  TUMORS  in  children  are  exceedingly  rare.  When 
found,  they  are  usually  dermoid  cysts,  carcinomata,  or  terato- 
mata. 

The  treatment  of  these  would  be  the  same  as  in  the  adult. 

UNDESCENDED  TESTICLE. 

Ordinarily  the  testes  descend  into  the  scrotum  during  the 
eighth  month  of  intra-uterine  life,  but  occasionally  children  are 
born  with  the  glands  still  within  the  abdominal  ring.  In  cases 
where  some  years  have  elapsed  without  the  descent  of  the  testi- 
cles it  is  quite  possible  that  atrophy  may  take  place,  although 
this  is  by  no  means  necessary.  It  sometimes  happens  that  one 
or  both  of  the  testicles  will  descend  and  return  to  the  abdominal 
cavity  again. 

Treatment. — The  location  of  the  gland  is  most  important 
in  determining  the  treatment.  In  cases  where  the  testicle  shows 
a  tendency  to  descend  it  should  be  allowed  to  do  so,  as  this  may 
take  place  even  after  a  lapse  of  several  years. 

The  majority  of  cases,  however,  will  require  surgical  inter- 
ference. For  the  details  of  such  operation  the  reader  is  referred 
to  surgical  works  upon  the  subject. 

TORSION  OF  THE  SPERMATIC  CORD. 

Occasionally  one  of  the  testes  is  twisted  upon  the  cord  suffi- 
ciently to  cause  constriction  of  the  circulation,  and  even  gan- 
grene. This  generally  happens  in  an  undescended  or  partially 
descended  testicle. 

It  is  very  difficult  to  differentiate  between  this  condition  and  a 
strangulated  hernia. 

Operation  is  necessary  :  the  cord  untwisted  if  possible,  or,  if 
there  be  any  doubt  as  to  the  vitality  of  the  tissues,  the  testicle 
and  cord  must  be  excised. 

HYPOSPADIAS. 

The  condition  known  as  hypospadias  is  the  result  of  arrested 
development  in  the  urethra  and  corpus  spongiosum.  Normally, 
the  urethral  groove  should,  by  the  uniting  of  its  sides,  be  con- 


326  DISEASES    OF    THE    GENITAL    ORGANS. 

verted  into  a  canal.  This  process  of  union  begins  at  the  base 
and  extends  to  the  end  of  the  penis,  and  arrest  of  this  process 
of  development  may  cause  the  urethra  to  open  at  any  point  along 
the  inferior  margin  of  the  penis.  In  female  children  the  urethra 
usually  opens  directly  into  the  vestibule. 

EPISPADIAS. 

In  males  this  variety  of  malformation  is  produced  by  the  ure- 
thral  canal  opening  upon  the  dorsum  of  the  penis.  It  is  very 
commonly  associated  with  extroversion  of  the  bladder.  Occa- 
sionally there  is  a  defect  in  the  union  of  the  anterior  abdominal 
wall  and  a  cleft  in  the  symphysis  pubis.  In  female  children  the 
anterior  wall  of  the  urethra  is  absent.  The  nymphae  and  clitoris 
are  generally  split. 

The  treatment  should  be  by  surgical  means. 


CHAPTER  X. 
DISEASES  OF  THE  BLOOD. 


GENERAL  CONSIDERATIONS  AND  DEFINITIONS. 

The  essential  features  for  consideration  in  a  study  of  the  blood 
are  its  coagulability  and  the  red  and  white  corpuscles.  Our 
knowledge  of  the  so-called  blood  plaques  or  plates  is  as  yet  too 
limited  to  warrant  more  than  a  reference  to  their  existence  in  this 
chapter. 

In  health  a  uniform  and  recognized  ratio  is  always  maintained 
between  the  number  of  the  red  and  white  cells,  although  slight 
discrepancies  occur  in  all  counts  made  of  the  same  specimen  by 
different  observers.  For  all  practical  purposes  the  normal  num- 
ber of  red  cells  is  estimated  at  5,000,000  in  a  cubic  millimeter, 
and  of  white  cells  at  7500  in  a  cubic  millimeter,  but  the  latter  may 
vary  in  health  from  5000  to  10,000.  Coles,  in  his  recent  work, 
says  that  Hayem  places  the  number  at  6000  and  von  Lembeck 
at  from  8000  to  9000.  The  proportion  of  white  to  red  cells  in 
normal  blood  is  as  I  to  500  or  600.  For  clinical  and  diagnostic 
purposes  a  careful  study  of  the  various  types  into  which  the 
white  corpuscles  are  divided  is  of  the  greatest  importance. 

It  is  very  essential  for  the  student  to  understand  the  few  facts 
that  follow,  to  enable  him  to  differentiate  the  separate  ages  or 
forms  of  the  white  cells  should  he  desire  to  make  a  blood 
examination  for  diagnostic  purposes.  The  youngest  white  cell  is 
the  "  lymphocyte,"  and  the  oldest  is  the  "eosinophile,"  and  the 
"  polymorphonuclear "  or  "  neutrophile  "  is  the  intermediate. 
The  lymphocyte  is  the  simplest  and  smallest,  as  well  as  the 
youngest,  and  consists  of  a  small  amount  of  protoplasm  with  a 
large  nucleus.  It  measures  from  6^  to  7^2  /*.  The  neutro- 
phile is  made  up  of  a  large  proportion  of  protoplasm  which  has 
already  become  granular,  and  an  irregularly  outlined  nucleus, 
often  horseshoe-like,  always  indented,  more  frequently  present- 
ing the  appearance  of  many  nuclei  (possibly  as  many  as  five) 
entirely  free  from  one  another,  but  usually,  upon  closer  examina- 
tion, they  will  be  found  connected  by  small  trabecular  bands. 

327 


328 


DISEASES    OF    THE    BLOOD. 


FIG.  31. 

a.  Small  lymphocyte,     b.  Large  lymphocyte,     c.  Transitional  lymphocyte,     d.  Neutrophiles. 
e.  Eosinophiles.   f.  Myelocyte.    g.  Eosinophilic  myelocyte. 


FIG.  32. 

a.  Normocyte.    b.  Parasites  of  quartan  fever,    c.  Parasites  of  tertian  fever,    d.  Parasites 

of  estivo-autumnal  fever. 


FIG.  33. 

a.  Normocyte.    b.  Normocyte  deficient  in  hemoglobin,    c.  Poikilocytes.    d.  Macrocyte. 
e.  Microcyte.  f.  Normoblasts.    g.  Megaloblast.    h.  Poikiloblast.    i.  Microblast. 


GENERAL    CONSIDERATIONS    AND    DEFINITIONS.  329 

The  neutrophile  is  larger  than  the  lymphocyte,  measuring 
from  /^  to  9^  <i.  The  eosinophile  is  more  highly  granular,  the 
granules  being  larger  and  more  refractile  than  in  any  other 
normal  cell,  its  nuclei  being  similar  to  that  of  the  neutrophile. 
The  size  of  this  cell  is  from  8  to  9^  //.  Often  white  cells  are 
observed  which  possess  morphologically  the  same  characteristics 
as  the  lymphocytes,  but  they  are  much  larger,  measuring  from 
8^  to  12  ft,  and  are  simply  named  the  "large"  lymphocytes. 
A  modification  of  this  cell  is  one  in  which  the  nucleus  becomes 
indented  or  kidney-shaped  and  its  protoplasm  shows  a  tendency 
to  become  granular.  It  is  known  as  the  "  transitional  cell." 
These  varieties  of  cells  bear  certain  numerical  relations  to  one 
another,  although  different  observers  give  different  proportions, 
as  will  be  seen  from  the  accompanying  table  : 

CABOT.             ROTCH.  STENGEL. 

PER  CENT.  PER  CENT.  PER  CENT. 

Lymphocytes,  small,     .    .  20     to  30  24  to  30  25 

Lymphocytes,  large,     .    .    4     to    8          3  to    6  3  to    6 

Neutrophiles, 62     to  70  60  to  75  65  to  70 

Eosinophiles, 0.5  to    4           I  to    2  Not  over    3. 

The  red  cells,  also  called  erythrocytes,  are  biconcave  discs, 
smooth,  homogeneous,  and  without  a  limiting  cell  membrane. 
In  health  three  sizes  of  these  corpuscles  are  found,  the  larger 
ones,  called  "  macrocytes  "  or  "  megalocytes,"  measuring  from 
8  to  9  //,  which  constitute  about  i2*/£  per  cent.  The  medium- 
sized  corpuscles  have  an  average  diameter  of  7  y2  p.,  and  consti- 
tute about  75  per  cent,  of  the  entire  number.  The  small  corpuscles, 
called  "  microcytes,"  measure  from  6  to  6T6^-  //,  and  constitute 
about  12^  per  cent.  (See  Fig.  33.) 

The  study  of  the  blood  for  clinical  purposes  is  greatly  facili- 
tated by  means  of  various  stains.  Multiple  staining  is  practically 
always  employed.  Many  workers  prefer  the  double  stain  of 
eosin  and  hematoxylin  or  eosin  and  methyl-blue,  while  others  use 
the  triple  stain,  after  the  method  of  Ehrlich,  the  formula  for 
which  is  as  follows  : 

Saturated  watery  solution  of  orange  G, 120  to  135  c.c. 

Saturated  watery  solution  of  acid  fuchsin, 80  to  165  c.c. 

Saturated  watery  solution  of  methyl-green,      ....  125  c.c. 

Glycerin, loo  c.c. 

Absolute  alcohol, 200  c.c. 

Distilled  water, 300  c.c. 

Eosin  solutions  are  made  to  the  strength  of  saturation,  and 
the  hematoxylin  solution  is  prepared  according  to  the  formula  of 
Delafield,  which  is  : 

Crystallized  hematoxylin, 4  c.c. 

Absolute  alcohol, r 25  c.c. 


33O  DISEASES    OF   THE    BLOOD. 

Mix  and  allow  to  stand  two  days,  then  add  400  c.c.  of  concen- 
trated aqueous  solution  of  ammoniac  alum,  stand  aside  for  four 
days,  leaving  it  uncorked  and  exposed  to  the  light.  Filter  and 
add  100  c.c.  of  glycerin  and  100  c.c.  of  wood-alcohol.  This 
solution  ripens  in  three  to  four  months,  and  for  careful  work 
should  not  be  used  until  it  has  been  prepared  for  that  time.  For 
staining  purposes  a  drop  of  blood  is  secured  from  the  well- 
cleaned  finger-tip  or  lobe  of  the  ear  upon  a  scrupulously  clean 
cover-glass.  Whichever  site  is  selected  should  be  carefully 
washed  with  soap  and  water,  afterward  with  alcohol  or  benzin. 
A  second  cover-glass  is  quickly  placed  over  the  first,  and  by 
rapidly  sliding  them  apart  two  smears  are  secured,  which  are 
dried  by  exposure  to  the  air.  An  hour  will  suffice,  although 
they  can  be  kept  indefinitely  in  this  condition,  and  especially  so 
if  they  be  protected  from  air,  dust,  and  moisture.  The  staining 
process  is  very  simple.  Heat  the  smears  for  about  an  hour 
upon  a  brass  plate  raised  to  such  a  temperature  that  a  drop  of 
water  will  evaporate  rapidly  from  its  surface,  then  stain  for  five 
minutes  with  a  hematoxylin  solution,  which  is  then  thoroughly 
washed  off  in  running  water,  and  the  film  afterward  allowed  to 
stand  for  two  or  three  minutes  in  water.  It  is  then  again  stained 
with  eosin,  and  after  drying  is  ready  to  be  mounted  in  balsam. 
An  oil-immersion  lens  should  always  be  used  for  blood  work. 

General  Pathologic  Changes. — Before  the  study  of  hemat- 
ology,  the  blood  was  considered,  pathologically,  solely  from  the 
clinical  evidences  of  an  increased  or  diminished  quantity  of  the 
fluid  in  relation  to  the  bodily  weight.  Little  attention  was  paid 
to  the  quality  or  to  the  condition  of  the  various  constituents. 
Plethora  was  described  as  a  condition  in  which  there  existed  an 
excessive  quantity  of  blood,  and  while  it  seems  evident  that  a 
transient  increase  in  the  total  amount  of  blood  is  a  possibility, 
yet  the  condition  is  purely  relative,  and  the  symptoms  observed 
are  the  result  of  vasomotor  disturbances.  The  opposite  condition 
to  plethora  was  indicated  by  the  term  anemia,  which  was  held  to 
represent,  in  a  general  way,  an  impoverished  state  of  the  blood. 
Oligemia  is  the  term  used  to  express  an  actual  reduction  in  the 
amount  of  blood  without  any  reference  to  component  parts. 
Oligocythemia  expresses  a  decrease  in  the  number  of  red  blood- 
corpuscles,  and  oligochromemia  expresses  the  diminution  in  the 
amount  of  hemoglobin  in  the  blood.  Hydremia  expresses  the 
fact  that  the  watery  element  of  the  blood  is  increased  beyond 
its  normal  amount,  and  anhydremia,  a  decrease  in  the  same  ele- 
ment. Lipemia  expresses  an  excess  of  fat  in  the  blood  and  is 
absolutely  of  no  clinical  significance,  although  it  is  found  in  a 


GENERAL    CONSIDERATIONS    AND    DEFINITIONS.  33! 

number  of  conditions,  such  as  phthisis,  nephritis,  diabetes,  etc. 
Melanemia  refers  to  pigments  in  the  blood  and  occurs  in  some 
infectious  diseases,  but  especially  in  malaria,  in  which  disease  it 
may  be  free  in  the  blood  after  a  paroxysm,  although  the  pigment 
is  normally  contained  in  the  corpuscles. 

An  increase  in  the  number  of  the  white  cells  may  affect  all 
varieties  of  these  cells,  but  especially  the  lymphocytes  and  neu- 
trophiles,  constituting  a  condition  known  as  leukocytosis.  A 
physiologic  increase  of  the  white  cells  is  at  times  observed,  and 
especially  is  this  liable  to  occur  after  eating,  an  hour  or  so  after 
which  the  white  corpuscles  may  be  increased  to  9000  or  10,000 
in  a  cubic  millimeter.  In  infants  this  is  especially  marked.  A 
pure  lymphocytosis  is  very  rarely  seen,  and  is  said  to  exist  when 
the  number  of  white  cells  reaches  10,000  in  a  cubic  millimeter, 
and  consists  of  an  increase  of  the  lymphocytes. 

Leukocytosis,  as  a  physiologic  condition,  exists  in  pregnancy, 
as  a  result  of  postpartum  hemorrhage,  after  violent  exercise,  a  cold 
bath,  and  massage.  The  moribund  state  is  also  accompanied  by 
a  leukocytosis.  Pathologically,  we  are  confronted  by  leukocy- 
tosis most  frequently  after  all  inflammatory  conditions,  and  a 
general  law  may  be  laid  down  that  the  leukocytosis  bears  a  direct 
relation  to  the  severity  of  the  infection  and  to  the  powers  of  resis- 
tance of  the  individual.  In  the  weak  and  emaciated,  with  low- 
resisting  power,  a  severe  septic  infection  will  not  cause  such  a 
degree  of  leukocytosis  as  a  similar  condition  would  give  rise  to 
in  the  strong  and  vigorous.  Should  the  disease  be  very  acute  and 
spreading,  the  leukocytosis  is  more  marked  than  when  it  has 
become  limited  and  walled  off.  This  has  been  more  thoroughly 
studied  in  appendicitis  than  in  any  other  disease.  Cabot  has  care- 
fully tabulated  many  diseases  during  the  course  of  which  a  leuko- 
cytosis is  found.  Among  children  it  is  most  frequently  seen  in  the 
infectious  diseases  :  scarlet  fever,  diphtheria,  follicular  tonsillitis, 
pneumonia,  smallpox,  cerebrospinal  meningitis,  and  among  the 
septic  diseases,  appendicitis,  abscesses  of  all  regions,  except  those 
of  tubercular  origin,  and  many  forms  of  skin  diseases.  When 
leukocytosis  is  absent  in  croupous  pneumonia,  it  is  a  very  bad 
prognostic  sign.  Many  diseases  that  produce  toxemias  also  pro- 
duce leukocytosis.  It  is,  however,  normally  absent  in  typhoid 
fever,  influenza,  malaria,  uncomplicated  measles,  and  almost  all 
tubercular  conditions,  so  long  as  there  is  not  a  mixed  infection. 

There  are  certain  intrinsic  changes  in  the  red  blood  elements 
which  are  important  in  diagnosis.  An  increase  in  the  propor- 
tion of  small  red  cells  is  called  microcythemia,  and  an  increase 
of  the  large  cells  is  called  macrocythemia.  The  importance 


332  DISEASES    OF    THE    BLOOD. 

of  microcythemia  has  not  been  clearly  made  out,  while  macro- 
cythemia  is  associated  with  all  the  severe  anemias.  When  any 
alteration  occurs  in  the  size  of  the  corpuscles,  there  are  usually 
found  associated  changes  in  their  forms.  Poikilocytosis  is  the 
term  used  to  designate  all  these  changes  in  shape.  Corpuscles 
may  be  rod-shaped,  pear-shaped,  etc.,  assuming  various  forms, 
in  the  place  of  the  uniformly  round  body.  Occasionally  all  the 
cells  may  appear  uniformly  but  irregularly  outlined,  owing  to 
faulty  technic. 

Red  blood-corpuscles  only  stain  as  they  die,  and  normally 
take  an  acid  stain  (eosin),  but  in  a  number  of  diseases,  such  as 
severe  anemia,  scarlet  fever,  and  smallpox,  a  few  red  corpuscles 
take  on  in  parts  the  second  stain.  This  condition  is  called  poly- 
chromatophilia,  and  is  an  evidence  of  cell  degeneration.  One 
observer  considers  it  an  evidence  of  cell  death.  Red  corpuscles 
may  show  small  knobs  projecting  from  the  spheric  border,  which 
become  detached  and  float  in  the  plasma.  Red  blood-corpuscles 
in  disease  take  on  the  fetal  phenomenon  of  nucleation.  Nucleated 
corpuscles  floating  in  the  peripheral  blood  are  comparatively 
rare,  and  it  may  require  many  examinations  of  the  same  specimen 
to  find  them.  Nucleated  corpuscles  are  of  three  sizes  !  the  normo- 
blast,  the  microblast,  and  the  megaloblast.  Normoblasts  occur 
normally  in  bone-marrow,  and  are  regarded  as  an  immature  red 
cell.  Their  presence  in  the  circulation  always  points  to  such 
blood  changes  wherein  the  demand  for  new  material  has  been 
greater  than  the  supply,  and  where  raw  material  had  to  be  drawn 
from.  On  the  contrary,  a  megaloblast  is  always  foreign  to  the 
healthy  body,  and  is  only  found  pathologically  and  in  the  fetal 
marrow.  Its  presence  is  indicative  of  a  severe  anemia.  In  size 
it  is  always  over  10  //,  and,  according  to  Cabot,  may  be  as  large 
as  20  fjt.  It  is  often  polychromatophilic.  The  nucleus  is  very 
large,  staining  less  intensely  than  a  normoblast,  and,  as  a  rule, 
uniformly.  When  present,  it  is  an  evidence  of  a  return  to  the 
fetal  hemogenesis,  and  that  the  bone-marrow  has  become  very 
seriously  deranged  in  its  function  of  blood  formation.  Megalo- 
blasts  may  also  be  poikilocytes.  Microblasts  are  smaller  than 
the  ordinary  red  cells,  and  have  probably  no  significance  other 
than  that  of  normoblasts  or  megaloblasts.  In  general  the  nucle- 
ated red  cells  are  evidences  of  severe  trouble,  and  occur  both  in 
primary  and  symptomatic  anemias.  Coles  says  that  normo- 
blasts may  always  be  looked  for  when  the  red  cells  do  not  exceed 
2,500,000  in  number.  However,  it  should  be  stated  that  the 
anemia  following  hemorrhage  must  be  very  severe  before  nucle- 
ated red  cells  are  found.  At  any  time  when  the  megaloblasts 


GENERAL    CONSIDERATIONS    AND    DEFINITIONS.  333 

exceed  the  normoblasts  the  condition  of  the  patient  is  very  seri- 
ous, and  especially  is  this  true  if  the  megaloblasts  are  also  poi- 
kilocytes.  Red  cells  may  sometimes  contain  granular  and  hyaline 
masses,  the  result  of  the  parasites  of  malaria,  which  will  be 
described  when  speaking  of  that  disease. 

Myelocytes,  or  marrow-cells,  never  occur  in  normal  human 
blood,  but  they  are  very  common  in  the  red  bone-marrow  and 
are  characteristic  of  mixed  and  splenomedullary  leukocythemia. 
Their  diameter  may  reach  20  /J..  The  nucleus  is  usually  single 
and  faintly  stained,  occupying  a  very  large  part  of  the  cell,  the 
remainder  of  which  is  highly  granular.  Occasionally  myelo- 
cytes  are  small,  and  were  it  not  for  the  fact  that  the  granules  take 
up  certain  stains,  such  as  Ehrlich's  neutral  stains,  they  could  not 
be  distinguished  from  large  and  small  lymphocytes.  These 
granules  do  not  stain  with  hematoxylin.  The  nucleus  is  often 
lobed.  Myelocytes  contain  at  times  eosinophilic  granules,  and 
are  then  called  eosinophilic  myelocytes.  The  chief  changes  in  the 
white  cells  are  in  their  numbers  and  proportions,  which  are  deter- 
mined by  the  differential  count. 

The  granules  found  in  the  white  cells  are  of  five  varieties  : 
Those  which  are  stained  by  the  acid  stains  and  are  called  "  eosin- 
ophiles,"  the  granules  of  which  are  large  and  round  ;  these  exist 
in  the  normal  blood.  "  Amphophiles "  contain  small  round 
granules  which  take  both  acid  and  basic  stains  and  do  not  nor- 
mally exist  in  the  human  blood,  but  in  the  medullary  cavity  of 
bones  and  in  the  leukocytes  of  some  of  the  lower  animals.  The 
so-called  "  Mast-cell,"  which  is  a  basophile, — that  is,  takes  a  basic 
stain, — contains  coarse,  round,  and  poorly  refracting  granules. 
Ehrlich  believes  they  do  not  occur  in  the  blood  normally,  but  if 
found  in  any  number,  are  pathognomonic  of  leukocythemia. 
Ordinary  stains  do  not  show  the  granules,  but  they  can  be 
readily  brought  out  by  the  use  of  the  following  solution,  in 
which  the  films  should  lie  twenty-four  hours  : 

Dahlia,  saturated  alcoholic  solution, 50  c.c. 

Glacial  acetic  acid, 10  to  15  c.c. 

Distilled  water, loo  c.c. 

The  granules  may  also  be  stained  with  methyl-blue.  The 
next  variety  is  only  distinguishable  by  the  size  of  the  granules, 
which  are  smaller  and  are  also  spoken  of  as  Mast  cells.  Both 
of  these  cells  are  mononuclear,  measuring  about  20  fj..  "  Neu- 
trophiles  "  are  those  cells  in  which  the  granules  take  only  the 
neutral  stain.  The  granules  are  fine,  and  fill  up  a  large  portion 
of  the  protoplasm  of  the  cells.  In  regard  to  both  varieties  of  the 


334  DISEASES    OF    THE    BLOOD. 

Mast  cells,  there  is  at  present  a  great  deal  of  doubt  in  the  minds 
of  different  observers.  The  eosinophilic  granules  he  calls  «, 
the  amphophilic  fj,  the  two  varieties  of  basophilic  f  and  d  respec- 
tively, and  the  neutrophilic  e. 

Blood  of  Infants. — In  infancy  the  hemic  equilibrium  is  re- 
markably unstable  and  subject  to  great  changes  from  trivial  causes. 
Diseases  which  ordinarily  cause  a  slight  leukocytosis  in  an  adult, 
cause  marked  increase  in  the  infant ;  especially  is  this  the  case 
with  anemia.  Normally  the  blood  of  a  very  young  child  does 
not  correspond  to  the  facts  recorded  of  adult  blood.  In  the 
count  of  the  red  blood-cells  of  an  infant  it  is  often  found  that 
there  will  be  an  increase  of  from  500,000  to  1,500,000  over 
that  of  a  normal  adult.  In  the  count  of  white  blood-corpuscles 
we  so  frequently  find  an  increased  number  that  we  may  almost 
assume  that  a  leukocytosis  is  normal  in  infancy.  Cases  have  been 
reported  where  there  were  20,000  leukocytes  during  the  first  few 
days  of  life,  and  this  number  increased  to  25,000  after  each  nurs- 
ing. This  post  cibium  increase  illustrates  the  fact  that  the  blood 
of  infants  is  readily  affected  by  trivial  affairs,  for  while  there  is  an 
acknowledged  leukocytosis  in  an  adult  after  eating,  it  never  occurs 
in  anything  like  this  degree.  Equally  remarkable  with  the  physi- 
ologic leukocytosis  is  the  proportion  in  the  respective  varieties,  as 
shown  by  differential  count.  The  lymphocytes  are  found  to  be 
more  numerous  than  in  adult  blood,  being  oftentimes  50  to  60 
per  cent,  of  the  whole,  in  the  place  of  20  to  30  per  cent.,  as  in 
adult  blood.  This  increase  is  at  the  expense  of  the  neutrophiles, 
which  oftentimes  are  only  20  or  30  per  cent,  in  the  place  of  60 
to  70  per  cent. 

Phagocytic  action  takes  place  in  the  neutrophile  cells,  demon- 
strating the  slight  power  of  resistance  in  infancy.  The  red  cells, 
also,  show  changes  in  infants  which  in  adults  would  be  pathologic. 
They  may  be  altered  in  shape  and  size  as  well  as  nucleated  (of 
the  variety  of  normoblasts). 

The  instruments  used  in  the  inspection  of  the  blood  are 
the  microscope,  the  hemocytometer,  the  hemoglobinometer,  the 
hematocrit,  and  the  spectroscope. 

Within  recent  years  the  literature  upon  this  fascinating  subject 
has  been  richly  increased,  and  the  reader  is  referred  to  that  for 
more  detailed  descriptions  of  the  instruments  used  and  the  tech- 
nic  employed,  which  can  not  be  given  in  this  chapter. 


PRIMARY    ANEMIAS. 


335 


ANEMIA. 

Anemia  is  divided  into  two  classes,  primary  and  secondary. 
First,  the  class  of  primary  anemias  containing  all  those  disorders 
which  are  essential  and  in  a  direct  manner  related  to  or  depen- 
dent upon  the  blood-making  organs,  and,  so  far  as  we  know,  bear 
no  relation  to  any  extraneous  causes.  This  class  includes  chloro- 
sis, leukocythemia,  pernicious  anemia,  pseudoleukemia  infantum, 
and  Hodgkin's  disease. 

Second,  the  secondary  or  symptomatic  anemias,  which  are  the 
result  of  some  other  distinct  disease  or  derangement  of  function 
and  are  not  due  to  disorders  of  any  of  the  organs  or  tissues 
directly  concerned  in  the  blood-making  function.  Hemorrhage 
from  any  cause  presents  the  most  perfect 
example  of  a  secondary  anemia.  It  is 
also  found  to  exist  in  association  with, 
and  after,  acute  fevers,  infectious  diseases, 
tubercular  diseases,  syphilis,  acquired  and 
hereditary,  rachitis,  malignant  growths, 
and  especially  in  children  after  gastric 
or  intestinal  diseases.  Morphan  believes 
that  primary  anemias  do  not  exist  in 
nurslings,  and  that  these  and  the  enlarge- 
ments of  the  various  organs  taking  part 
in  the  production  of  blood  depend  upon 
some  acute  or  chronic  infection.  He 
also  believes  that  hypertrophies  of  the 

spleen,  liver,  and  lymphatic  glands  are  very  prone  to  appear  in 
any  of  the  anemias  of  childhood. 

In  all  forms  of  anemia  the  so-called  hemic  murmur  can  be 
found.  However,  in  the  anemia  of  children  these  inorganic 
murmurs  are  very  rare  until  after  the  third  year.  In  all  anemias 
of  children,  and  particularly  of  infants,  the  changes  found  in  the 
blood  are  much  greater  than  those  under  similar  conditions  in 
the  adult.  These  changes  consist  of  a  nucleation  of  the  white 
corpuscles  and  in.  increase  in  the  proportion  of  the  lymphocytes, 
associated  at  times  with  irregularly  shaped  red  cells. 

PRIMARY  ANEMIAS. 

CHLOROSIS. 
Synonyms. — CHLOREMIA  ;    GREEN  SICKNESS. 

Definition. — Chlorosis  is  an  essential  anemia  occurring  chiefly 
in  young  girls  at  about  the  period  of  adolescence.  It  is  charac- 


FIG.  34. — HUMAN  COLORED 
BLOOD  -  CORPUSCLES.  — 
{After  Landois.) 

i.  On  the  flat.  2.  On  edge. 
3.  Rouleau  of  corpus- 
cles. 


336  DISEASES    OF    THE    BLOOD. 

terized  by  a  diminution  in  the  percentage  of  hemoglobin,  the 
various  evidences  of  anemia,  and  changes  in  the  vascular  sys- 
tem. 

Causes. — Among  the  predisposing  factors  which  are  potent 
in  the  causation  of  this  disease  sex  stands  preeminent.  Chloro- 
sis seems  to  be  confined  chiefly  to  the  female  sex,  and  is  rarely 
seen  in  other  than  ill-nourished  girls  about  the  age  of  puberty, 
although  cases  have  been  reported  in  females  before  reaching  this 
period  by  Nonat  and  others.  Chlorosis  exists  in  boys  in  a  some- 
what modified  form.  Heredity  undoubtedly  plays  an  important 
part  as  a  predisposing  cause.  The  statement  that  light-haired 
girls  of  poor  vitality  are  especially  predisposed  to  chlorosis  has 
been  generally  refuted,  although  the  question  is  still  unsettled. 
The  causes  which  may  be  directly  responsible  for  the  develop- 
ment of  the  disease  are,  on  one  hand,  overwork  and  poor 
nourishment,  and,  on  the  other,  indolence,  vicious  habits,  and  bad 
sanitation.  Powerful  nervous  impressions  may  act  as  strong  in- 
fluences in  the  development  of  the  disease. 

Pathology. — Many  have  looked  upon  chlorosis  as  dependent 
upon  disturbances  of  menstruation,  and  not  a  few  have  held  to 
the  theory  that  gastro-intestinal  disorders  are  the  cause  of  this 
disease.  So  far  the  causative  element  has  not  been  demonstrated, 
but  the  consensus  of  opinion  is  that  chlorosis  is  dependent  upon 
imperfect  nutrition  and  sanitation.  It  may  also  depend  upon  a 
copremia  due  to  absorption  from  the  bowels  of  ptomains  or 
leukomains. 

Anatomic  Changes. — The  heart  and  blood-vessels  in  chlo- 
rosis are  in  a  state  of  hypoplasia  and  are  usually  ill  developed. 
Fatty  degeneration  of  the  cardiac  muscle  and  arterial  coats  has 
frequently  been  demonstrated.  The  same  condition  of  hypo- 
plasia is  often  seen  in  the  genital  organs, -they  frequently  present- 
ing an  infantile  appearance.  While  any  or  all  of  the  foregoing 
changes  may  be  noted,  they  are  by  no  means  constant. 

Blood  Changes. — The  specific  gravity  of  the  blood  in  chlor- 
osis is  low,  being  often  only  1035.  On  account  of  this  low 
specific  gravity  and  the  inaccuracies  of  the  von  Fleischl  apparatus 
in  low  readings,  the  table  on  page  354  will  be  found  useful  in 
studying  this  disease.  The  color  of  the  blood  as  it  flows  from  a 
prick  wound  is  light.  Coagulation  takes  place  rapidly,  and  man- 
ipulations therefore  must  be  rapid.  The  blood  is  obviously  thin 
and  watery. 

The  essential  change  in  the  blood  is  a  decrease  in  the  actual 
amount  and  percentage  of  hemoglobin  present  in  each  corpuscle. 
There  is  probably  no  diminution  in  the  total  amount  of  the  blood. 


PRIMARY    ANEMIAS.  337 

The  reduction  of  the  hemoglobin  occurs  with  or  without  a  ma- 
terial decrease  in  the  red  corpuscles,  while  in  the  severer  cases 
they  are  decidedly  decreased  in  number.  Should  the  case  be  put 
upon  the  usual  treatment  of  iron  and  arsenic  and  observations 
frequently  made,  the  red  blood-corpuscles  may  be  found  increased 
in  number  and  the  amount  of  hemoglobin  stationary,  or  nearly 
so.  The  color  index  is  always  low,  being  from  0.5  to  0.35  or 
even  to  0.3. 

The  average  amount  of  hemoglobin  in  chlorosis  is  about  40 
per  cent*.  Out  of  247  cases  mentioned  by  Coles,  as  tabulated 
by  various  writers,  40  per  cent,  showed  a  blood  count  of  4,000,- 
OOO  corpuscles,  and  60  per  cent,  of  less  than  that  number.  It 
is  rare  to  find  a  very  low  count,  such  as  occurs  in  pernicious 
anemia.  The  diminution  of  the  hemoglobin  is  found  after  cer- 
tain diseases,  while  the  blood  is  being  regenerated,  but  not  to 
the  same  degree  as  in  chlorosis.  Certain  changes  take  place  in 
the  red  corpuscles.  Microcytes  exist  and  may  be  so  numerous 
that  the  general  average  of  the  diameters  of  the  blood-corpus- 
cles is  reduced.  The  corpuscles  may  be  changed  in  shape,  but 
the  degree  of  poikilocytosis  is  not  dependent  upon  the  decrease 
of  the  red  cells. 

In  staining  specimens  many  red  cells  fail  to  take  on  the  average 
amount  of  staining.  Polychromatophilia  exists,  demonstrating 
the  mortal  changes  in  the  cells.  The  occurrence  of  nucleated 
red  cells  has  been  denied  by  some  writers,  but  the  positive  evi- 
dence of  others  would  seem  to  settle  the  matter.  They  occur 
only  in  very  severe  cases  and  are  usually  normoblasts,  while  the 
occurrence  of  megaloblasts  in  the  most  extreme  cases  is  rare. 

In  all  uncomplicated  cases  of  chlorosis  the  white  cells  remain 
about  normal.  There  is  never  a  leukocytosis,  though  there  may 
be  a  diminution  of  the  white  cells.  Rarely  a  few  myelocytes  are 
found.  Cabot  records  a  table  of  white-cell  counts  in  which  the 
highest  count  was  15,000  and  the  lowest  1500  ;  the  average  was 
7485.  In  those  cases  where  the  count  was  high  there  was  some 
other  condition  prevailing. 

Symptoms. — The  premonitory  symptoms  of  chlorosis  are 
varied,  sometimes  rather  vague.  Frequently  they  are  unnoticed, 
except  that  the  patient,  before  in  good  health,  develops  a  gradual 
increase  in  lassitude,  which  is  often  attributed  to  the  onset  of 
puberty  or  the  effect  of  overwork.  Later  there  are  menstrual 
irregularities.  Shortness  of  breath  and  palpitation  of  the  heart 
are  complained  of  frequently.  Headache  is  common  ;  in  fact,  in 
some  cases  may  be  almost  constant.  Dizziness  and  weakness, 
increased  upon  standing  and  walking,  are  usually  noticed.  The 


338  DISEASES    OF    THE    BLOOD. 

digestion  becomes  weak,  the  appetite  fails,  and  the  patient  often 
craves  abnormal  articles  of  food.  The  skin  develops  a  peculiar 
greenish-yellow  tint  which  is  eminently  characteristic  of  the  dis- 
ease. The  mucous  membranes  become  pale,  and  the  conjunc- 
tivas in  severe  cases  almost  colorless.  In  some  cases  the  cheeks 
and  lips  retain  their  natural  color,  even  though  the  hemoglobin 
shows  a  pronounced  reduction.  To  this  class  of  cases  Wendt 
has  applied  the  name  of  chlorosis  florida  or  chlorosis  rubra. 
Occasionally  marked  pigmentation  is  observed  in  the  neighbor- 
hood of  the  joints.  Edema  beneath  the  eyes  and  of  the  malleoli 
is  commonly  observed,  and  oftener  toward  the  end  of  the  day 
than  in  the  morning.  There  is  a  tendency  to  the  accumulation 
of  fat,  making  the  patient,  as  a  rule,  rather  flabby  than  ema- 
ciated. The  disturbances  of  circulation  are  generally  manifest 
by  visible  pulsations  of  the  veins  of  the  neck.  Coldness  of  the 
extremities  and  palpitation  of  the  heart  are  very  frequently  com- 
plained of.  The  pulse  is  generally  rapid  and  weak.  Examina- 
tion of  the  heart  seldom  reveals  any  change  in  its  size.  The 
apex-beat  is  usually  visible  and  strong  ;  hemic  murmurs  are 
heard  upon  auscultation,  most  frequently  over  the  pulmonary 
area,  and  at  times  a  soft  systolic  bruit  may  be  elicited  at  the 
apex.  Not  infrequently  a  hemic  murmur  will  be  heard  over  the 
right  jugular  vein.  This  is  sometimes  known  as  the  bruit  de 
diable,  or  "humming-top"  murmur.  Hemorrhages  are  not 
uncommon,  and  maybe  due  to  degeneration  of  the  arterial  coats 
or  to  the  blood  itself.  The  nervous  symptoms  are  many  and 
varied  ;  cephalalgia  and  neuralgia  are  rarely  absent,  while  hys- 
teric manifestations  of  a  varied  and  sometimes  grave  character 
are  not  at  all  uncommon.  Optic  neuritis  and  neuroretinitis  have 
been  recorded  as  symptoms  by  Gowers. 

Complications. — A  large  number  of  cases  of  chlorosis  pre- 
sent no  complications.  Occasionally,  however,  endocarditis  and 
enlargement  of  the  thyroid  gland  are  seen.  Thrombosis  of  the 
veins  was  first  observed  by  Trousseau,  and  occurs  more  frequently 
than  is  generally  supposed.  Gastric  ulcer,  nephritis,  and  phthisis 
are  frequent  complications. 

Diagnosis. — Anemia  in  a  young  woman  with  cardiac,  diges- 
tive, and  menstrual  irregularity,  a  greenish-yellow  tint  of  the 
skin,  certain  nervous  disturbances  associated  with  a  diminution 
of  the  hemoglobin,  very  little  changes  in  the  blood  count  as 
compared  with  the  decrease  in  the  hemoglobin,  render  the  diag- 
nosis easy.  We  are  able  in  no  instance  to  depend  upon  the  blood 
examination  alone  for  the  diagnosis,  or  we  should  be  confusing 
it  with  syphilis,  tuberculosis,  malignant  diseases,  and  other  dis- 


PRIMARY   ANEMIAS.  339 

eases  which  present  secondary  anemia.  Leukocytosis  is  very 
common  in  secondary  anemia  and  absent  in  simple  chlorosis. 

Prognosis. — The  prognosis  of  chlorosis  is  favorable.  There 
are  exceptional  cases,  however,  which  resist  treatment.  Chloro- 
sis is  generally  amenable  to  treatment  in  from  six  to  eight  weeks, 
but  sometimes  it  is  most  obstinate  and  prolonged. 

Treatment. — In  chlorosis,  as  well  as  in  the  various  symptom- 
atic anemias,  special  attention  should  be  given  to  the  environment 
of  the  patient.  In  many  cases  the  rest  cure  or  one  of  its  modi- 
fications will  be  found  necessary.  This  method  of  treatment  is 
particularly  applicable  to  those  patients  whose  lives  have  been 
spent  at  hard  work  in  a  close  atmosphere.  For  those  whose 
means  will  allow  it,  a  sea  voyage  is  to  be  recommended,  and  in 
cases  where  this  luxury  can  not  be  had,  quiet  recreation  in  a 
neighboring  park  or  several  hours  spent  in  the  sunshine  in  a  pub- 
lic square  should  be  insisted  upon.  Medicinally,  iron  can  be 
claimed  as  a  specific  in  the  disease,  and  of  all  the  forms  of  iron 
which  we  have  at  our  command,  Blaud's  pills,  containing  equal 
parts  of  the  dry  sulphate  of  iron  and  the  carbonate  of  potassium, 
have  probably  given  the  most  satisfaction.  Where,  for  any  rea- 
son, pills  can  not  be  taken  by  the  patient,  the  powdered  saccha- 
rated  carbonate  or  some  liquid  preparation  of  iron  should  be 
used.  The  tincture  of  the  chlorid  will  often  be  found  extremely 
beneficial.  Da  Costa  says  the  occasional  use  of  the  ferrous 
manganese  citrate  has  given  satisfactory  results.  During  a  long 
course  of  iron  treatment  constipation  will  sooner  or  later  result, 
and  therefore  the  administration  of  the  drug  should  be  so  regu- 
lated as  to  avoid  this  objectionable  feature.  The  natural  iron 
waters  are  here  of  special  use.  Constipation  can  generally  be 
overcome  by  the  occasional  use  of  small  doses  of  a  laxative — a 
saline,  cascara,  senna,  or  bowel  irrigation.  Next  in  efficacy  to 
iron  in  the  treatment  of  chlorosis  is  arsenic.  The  good  results 
of  the  latter  are  much  increased  in  many  cases  by  combining 
arsenic  with  iron.  Arsenic  may  be  given  in  increasing  doses 
until  a  decided  physiologic  action  of  the  drug  is  obtained.  In 
most  cases  massage  will  be  found  an  admirable  adjunct  in  the 
treatment.  A  powerful  agent  in  combatting  the  effects  of  anemia 
is  systematic  deep  breathing  and  respiratory  gymnastics. 

SIMPLE  PRIMARY  ANEMIA. 

Simple  primary  anemia  per  se  is  a  condition  about  the  exist- 
ence of  which  there  has  been  some  doubt,  but  many  describe  it 
as  a  special  condition.  It  occurs  without  any  distinct  pathologic 


34O  DISEASES    OF    THE    BLOOD. 

alterations,  and  is  not  associated  with  any  severe  or  marked  con- 
stitutional symptoms  other  than  those  which  occur  in  chlorosis 
or  any  other  disease  where  there  is  a  diminution  of  the  blood  or 
of  its  normal  elements.  Its  etiology  is  doubtless  due  to  the 
effects  of  poor  hygienic  surroundings  and  a  consequent  lack  of 
proper  activity  of  the  blood-making  organs.  One  very  important 
fact  is  the  rapidity  with  which  the  blood  reaches  its  normal  level 
when  the  patient  gets  fresh  air,  proper  food,  and  exercise.  The 
changes  in  the  blood  are  a  proportionate  diminution  of  the  red 
cells  and  of  hemoglobin.  In  the  severer  cases  evidences  are 
shown  of  degeneration  in  the  blood-cells  in  the  form  of  megalo- 
cytes,  normoblasts,  and  megaloblasts.  Microcytes  may  also  be 
found.  There  is  also  a  decrease  in  the  hemoglobin  out  of  pro- 
portion to  the  number  of  the  red  cells.  The  red-blood  count 
falls  as  low  as  1,000,000,  and  the  hemoglobin  to  30  or  40  per 
cent.  This  extreme  is  very  exceptional.  The  white  cells  show 
no  changes  beyond  that  expected  from  a  decrease  in  the  general 
tone  of  the  blood.  In  those  cases  where  there  may  be  a  leuko- 
cytosis  or  a  relative  change  in  the  quantity  of  lymphocytes  or 
neutrophiles,  some  other  condition  must  be  searched  for. 

> 

• 

SPLENIC  ANEMIA. 
Synonym. — SPLENIC  PSEUDOLEUKEMIA. 

There  is  a  decrease  in  the  number  of  red  corpuscles,  micro- 
cytes  are  quite  numerous,  and  there  is  a  loss  of  hemoglobin  out 
of  proportion  to  the  decrease  of  the  red  cells.  The  color  index 
is  low  and  the  leukocytes  are  unchanged. 

LEUKOCYTHEMIA. 
Synonyms. — LEUKEMIA  ;  WHITE  BLOOD  ;  ANAEMIA  SPLENICA. 

Definition. — Leukocythemia  is  a  primary  or  essential  anemia, 
characterized  by  excessive  increase  in  white  blood-cells  and  by 
an  enlargement  of  the  spleen  or  lymphatic  glands,  with  changes 
in  the  bone-marrow. 

Causes. — Leukocythemia  may  occur  at  any  period  of  life  from 
infancy  to  old  age,  and  although  comparatively  a  rare  disease,  it 
is  as  common  among  the  rich  as  the  poor.  The  infectious  origin 
of  the  disease  has  been  urged  ably  by  many  good  observers,  but 
no  proof  is  exhibited  as  yet. 

Among  the  predisposing  causes  heredity  has  commanded  con- 
siderable attention.  Instances  are  recorded  bearing  proof  of  the 


PRIMARY    ANEMIAS.  34! 

importance  of  this  factor  in  the  development  of  the  disease.  Leu- 
kemia has  been  frequently  met  with  after  severe  attacks  of  ma- 
laria. However,  the  latter  disease  is  looked  upon  as  a  predisposing 
rather  than  an  exciting  cause.  Syphilis,  rachitis,  typhoid  fever, 
and  severe  hemorrhages  have  all  been  mentioned  as  predisposing 
causes.  The  exciting  cause  of  the  disease  has  not  yet  been  de- 
termined. 

Pathologic  Anatomy. — Leukemia  is  essentially  a  disease  of 
hemogenic  alterations  in  the  blood-making  organs.  The  lymph- 
atic structures  are  principally  involved,  and  pathologic  lesions  are 
noticed  in  the  spleen  and  bone-marrow. 

From  this  fact  three  varieties  of  leukocythemia  have  been  de- 
scribed :  a  splenic,  a  medullary,  and  a  lymphatic.  However, 
since  pure  splenic  cases  and  medullary  cases  rarely,  if  ever,  occur, 
though  there  is  no  doubt  that  one  or  other  of  these  elements  may 
at  times  predominate,  it  is  wise  to  outline  but  two  classes  of 
leukocythemia.  This  is  especially  noted  in  the  works  of  the 
later  writers,  who  declare  that  the  splenic  and  medullary  varieties 
are  always  blended  and  that  even  the  lymphatic  variety  may  be 
associated  with  the  other  two.  The  divisions  of  leukocythemia, 
then,  are  first  the  splenomedullary,  in  which  we  find  the  spleen 
enlarged,  congested,  and  infiltrated  with  leukocytes,  and  the 
bone-marrow  of  the  long  and  spongy  bones  of  a  yellowish  hue, 
either  in  small  patches  throughout  the  marrow  or  uniformly 
present.  This  material  may  be  firm  at  first,  though  in  time  it 
softens  down  and  eventually  much  resembles  pus.  The  fat  has 
been  replaced  by  a  purulent  or,  as  Newman  says,  a  pyoid, 
material.  The  microscope  shows  both  varieties  of  marrow-cells, 
and  on  account  of  the  very  large  number  of  cells  showing 
karyokinesis  and  in  the  process  of  division,  it  is  evident  that 
proliferation  has  been  going  on.  The  nucleated  red  cells  lie 
along  the  periphery  of  the  marrow.  The  occurrence  of  these 
cells  in  the  blood  is  explained  by  the  escape  of  all  these  elements 
from  the  bone -marrow  into  the  blood.  The  cause  of  this  con- 
dition has  not  yet  been  determined. 

Second,  lymphatic  leukocythemia  is  characterized  by  the  en- 
largement of  the  lymphatic  glands  and  the  substitution  of  lym- 
phoid  tissue  for  the  bone-marrow.  This  lymphoid  tissue  consists 
of  small  mononuclear  lymphocytes  and  some  nucleated  red  cells. 
The  spleen  in  this  variety  also  shows  some  enlargement.  The 
lymphatic  glands  are  not  always  enlarged,  nor  does  the  spleen 
always  appear  to  take  a  minor  part,  since  in  rare  cases  it  is  quite 
large.  The  essential  feature  is  an  excessive  proliferation  of  the 
lymphocytes.  The  cause  of  this  condition  is  not  known.  In 


342  DISEASES    OF    THE    BLOOD. 

this  disease  the  white  cells  show  a  very  appreciable  increase  when 
examined  by  the  hematocrit. 

The  Blood  in  LeukocytJiemia. — There  are  certain  facts  about  the 
blood  that  apply  to  both  forms  of  leukocythemia.  Its  color  is 
usually  normal,  though  when  the  white  corpuscles  are  very 
numerous,  it  is  described  as  chocolate,  but  it  sometimes  looks 
like  pus  and  blood  mixed,  or  it  may  be  very  pale.  Its  specific 
gravity  is  low,  its  reaction  is  alkaline,  and  it  coagulates  readily. 
Under  the  microscope,  without  stain,  the  disproportion  can  be 
seen  between  the  white  and  red  cells,  and  if  it  be  a  splenomed- 
ullary  case,  the  large  size  of  the  white  cells  can  be  noted.  The 
leuckocytes  are  enormously  increased  in  number,  sometimes  as 
many  as  500,000  being  found,  and  a  count  of  100,000  to  200,000 
is  not  unusual.  The  proportion  of  white  to  red  may  be  i  to  12, 
while  that  in  health  is  I  to  500  or  600.  A  few  remarkable  cases 
have  been  reported  where  the  proportion  was  I  to  2.  It  is 
important  to  understand  that  it  is  not  the  actual  number  or  pro- 
portion of  the  white  cells  present  which  makes  the  diagnosis, 
but  that  it  is  the  character  of  the  cells.  A  leukocytosis  exists 
oftentimes  to  a  very  marked  degree,  while  the  normal  ratio  of  the 
different  varieties  of  white  cells  remains  ;  in  other  words,  it  is 
quality  we  look  for  and  not  quantity.  In  leukocytosis,  if  any 
intercurrent  and  infectious  disease  should  arise,  the  leukocytes 
grow  fewer  in  a  remarkable  degree. 

Splenomedullary  leukocythemia  is  the  commoner  of  the  two 
forms.  Should  one  not  have  at  hand  a  case  of  the  disease  to 
study,  it  can  very  readily  be  worked  up  from  the  bone-marrow 
of  a  kitten  mixed  with  its  ordinary  blood.  The  alterations  are 
in  the  forms  and  varieties  as  well  as  in  the  number  of  the  leuko- 
cytes. The  blood  should  be  stained  for  study.  The  character- 
istic cell  is  the  myelocyte.  The  existence  of  the  myelocyte  in  a 
blood-stain  will  not  establish  the  diagnosis,  but  when  these  cells 
exist  in  large  numbers,  then  it  would  be  just  to  make  this  diag- 
nosis— 30  to  50  per  cent,  of  all  leukocytes  seems  to  be  the  aver- 
age number.  The  neutrophiles  are  very  much  decreased  in  rel- 
ative numbers,  though  the  actual  number  of  these  cells  present 
may  be  enormously  increased.  The  differential  count  shows 
about  50  per  cent,  of  neutrophiles,  occasionally  dropping  as  low 
as  1 5  to  20  per  cent.  They  are  smaller  and  more  irregular  in 
shape  than  in  health.  The  eosinophiles  are  increased,  averaging, 
according  to  Cabot's  table,  4-^  per  cent.  In  one  case  there  was 
1 1  per  cent. 

There  are  three  classes  of  eosinophiles  present :  First,  the 
ordinary  polynuclear  eosinophile ;  second,  a  small  eosinophile 


PRIMARY   ANEMIAS.  343 

that  is  deeply  stained  with  eosin  and  that  does  not  occur  in  the 
human  blood,  and  which  has  been  thought  to  be  characteristic 
of  this  state  ;  third,  the  eosinophilic  myelocyte,  which  never 
occurs  in  health  and  is  characteristic  of  this  disease.  The  lymph- 
ocytes, as  a  rule,  are  much  reduced  in  their  proportion,  being 
often  as  low  as  5  per  cent,  in  the  place  of  from  15  to  25  per 
cent.,  as  in  health.  Karyokinetic  figures  may  be  found. 

The  number  of  red  cells  is  not  extremely  diminished,  being 
reduced  from  two  to  three  millions.  The  shape  and  size  re- 
main about  the  same.  Nucleated  red  cells  are  constantly  found 
in  leukocythemia,  and  it  is  said  that  this  is  the  only  disease  in 
which  they  occur  in  such  numbers.  They  are  normoblasts,  with 
an  occasional  megaloblast.  The  hemoglobin  is  decreased  in  pro- 
portion to  the  decrease  of  the  red  cells.  Blood  plates  are 
increased,  and  Charcot-Leyden  crystals  are  found  in  dried  speci- 
mens. 

Lymphatic  Leukocythemia. — This  form  is  rare  and  more  acute 
than  the  preceding  disease  ;  it  is  characterized  by  an  increase  in 
the  size  of  the  lymphatic  glands  and  the  occasional  enlargement 
of  the  spleen,  and  by  the  following  blood  changes  :  There  is  an 
increase  in  the  white  cells  which  is  never  so  extensive  as  in  the 
splenomedullary  type,  ranging  about  1 50,000  cells  in  a  cubic 
millimeter,  though  there  may  be  as  low  as  40,000  or  as  high  as 
450,000.  Lymphocytes  predominate,  and  may  form  as  much  as 
95  per  cent,  of  all  of  the  white  cells.  In  no  other  disease  does 
such  a  state  constantly  exist.  The  lymphocytes  are  large  and 
small,  depending  upon  the  case.  A  few  myelocytes  may  be 
found.  Red  blood-corpuscles  and  hemoglobin  are  diminished, 
and  nucleated  red  cells  are  rare. 

Symptoms. — Leukocythemia  usually  comes  on  so  insidiously 
that  the  patient  does  not  become  aware  of  his  condition  until  the 
disease  is  fairly  well  developed.  The  early  symptoms  are  those 
of  a  developing  anemia,  with  its  attending  phenomena  of  weak- 
ness, cardiac  palpitation,  shortness  of  breath,  and  pallor,  together 
with  hemorrhages  from  the  mucous  membranes.  Pain  in  the 
splenic  area  not  infrequently  ushers  in  the  attack.  Priapism  has 
been  cited  by  Edes  and  others  as  an  early  symptom  of  the 
disease.  The  abdomen  soon  becomes  noticeably  increased  in 
size,  due  to  the  enlargement  of  the  spleen  and  various  lymphatic 
structures.  There  is  considerable  fluctuation  in  the  size  of  the 
spleen  ;  examination  may  show  the  organ  to  be  hypertrophied  to 
such  an  extent  as  to  reach  the  spines  of  the  ilia,  while  a  subse- 
quent examination,  after  a  lapse  of  some  hours,  may  reveal  the 
organ  decreased  to  one-half  of  its  former  size.  The  involvement 


344  DISEASES    OF    THE    BLOOD. 

of  the  lymphatic  glands,  especially  those  of  the  neck,  is  very 
common.  These  glands  are  of  stony  hardness,  and  apt  to  pro- 
duce pressure  symptoms,  impeding  respiration.  Vertigo  is  con- 
stant, and  is  generally  caused  by  the  intense  anemia.  The  skin 
is  of  a  pale,  ashen  color  ;  sometimes  it  has  a  dirty  yellow  hue, 
but,  as  in  chlorosis,  the  patient  may  preserve  the  healthy  hue  of 
the  cheeks,  which  appearance  is  very  deceptive.  Various  skin- 
lesions,  as  noted  in  the  pathology,  are  apt  to  develop,  and  sub- 
cutaneous edema  is  rarely  absent.  The  pulse  is  quick  and  com- 
pressible ;  hemic  murmurs  are  heard  at  the  base  of  the  heart  and 
in  the  vessels  of  the  neck.  The  circulatory  disturbances  are 
simply  those  of  intense  anemia.  The  liver  is  nearly  always  en- 
larged, and  gastro-intestinal  symptoms  prevail.  Diarrhea  and 
vomiting  are  occasionally  met  with.  The  tendency  to  hemor- 
rhage is  a  marked  feature  of  the  disease,  and  cases  are  recorded 
in  which  the  loss  of  blood  in  a  single  flow  has  been  such  as  to 
endanger  the  life  of  the  patient.  Nervous  symptoms,  as  a  rule, 
are  not  well  marked  ;  of  these,  headache  and  melancholy  are  the 
most  constant. 

Diagnosis. — The  diagnosis  of  leukocythemia  is  often  sur- 
rounded with  many  difficulties.  Hodgkin's  disease  and  the  con- 
dition of  leukocytosis  are  apt  to  be  confounded  with  it.  In 
Hodgkin's  disease  we  have  either  no  increase  of  the  leukocytes 
or,  if  any,  only  a  very  moderate  one,  and  if  there  be  an  increase, 
it  is  in  the  neutrophiles.  Between  this  and  leukocythemia  it  is 
only  during  a  remission  that  the  diagnosis  could  be  questioned. 
Leukocytosis  can  be  differentiated  by  a  failure  to  find  myelo- 
cytes,  an  increase  of  neutrophiles  and  lymphocytes,  and  also  by 
the  absence  of  pathologic  red  cells  and  by  the  number  and  pro- 
portion of  the  neutrophilic  leukocytes.  Typhoid  fever  can  easily 
be  differentiated  by  the  absence  of  leukocytosis.  Frequent  counts 
of  the  red  and  white  cells  and  microscopic  examination  of  stained 
slides  are  the  only  methods  of  making  an  absolute  diagnosis. 

Prognosis. — The  course  of  the  disease  is  chronic,  and  the 
prognosis  is  extremely  grave. 

Treatment. — Cases  have  recovered.  Absolute  rest  is  of 
primary  importance.  The  personal  hygiene  should  be  carefully 
attended  to  ;  easily  digested  diet  should  be  given,  attention  being 
directed  to  the  quantity  of  food  given  at  each  meal.  Arsenic  has 
proved  by  far  the  most  valuable  of  all  drugs  recommended  in  the 
treatment  of  this  disease.  Fowler's  solution  in  increasing  doses 
is  perhaps  the  most  efficient  method  of  administering  the  drug. 
Quinin,  iron,  and  strychnin  prove  valuable  only  as  general  tonics. 
Symptoms  should  be  treated  as  they  arise.  In  regard  to  the  re- 


PRIMARY    ANEMIAS.  345 

moval  of  the  large,  painful  spleen,  the  operation  of  splenectomy 
has  proved  disastrous  in  every  case  save  the  first  one,  and  is 
therefore  inadvisable. 

PSEUDOLEUKOCYTHEMIA    INFANTUM. 

This  disease  is  associated  with  an  enlargement  of  the  spleen 
and  a  moderately  enlarged  liver,  sometimes  enlargement  of  the 
lymphatic  glands,  with  a  decrease  in  the  hemoglobin  and  red 
blood-cells  and  a  degree  of  leukocytosis.  Nucleated  red  blood- 
cells  have  been  described,  and  poikilocytosis  may  occur.  It  is 
a  disease  that  occurs  in  early  infancy  and  usually  runs  a  favor- 
able course.  The  child  is  very  pale  and  waxen  in  appearance. 
Recent  writers  consider  it  a  secondary  condition  and  think  that 
the  changes  noted  depend  upon  some  gastro-intestinal  condition 
and  the  age  of  the  patient. 

PROGRESSIVE  PERNICIOUS  ANEMIA. 

Definition. — A  grave  progressive  form  of  anemia,  dependent 
upon  hemolytic  disturbances,  characterized  by  the  presence  of 
abnormalities  and  a  great  reduction  in  the  number  of  red  cor- 
puscles without  a  corresponding  loss  of  hemoglobin,  and  almost 
invariably  ending  in  death. 

Causes. — The  true  cause  of  this  disease  is  unknown.  It  has 
been  asserted  that  ptomains  absorbed  from  the  alimentary  canal 
were  instrumental  in  its  etiology.  This,  as  well  as  the  infectious 
theory,  has  not  been  substantiated.  Pernicious  anemia  occurs  in 
middle  life,  but  occasionally  may  be  seen  in  children.  It  is, 
however,  rare  in  the  earlier  years  of  life. 

Morbid  Anatomy. — The  skin  presents  a  pallid,  yellowish  cast, 
and  this  pallor  may  be  shared  by  the  mucous  membranes.  The 
muscles  in  contrast  to  the  external  organs  are  remarkably  red  in 
color.  A  considerable  amount  of  serous  effusion  is  occasionally 
met  with,  especially  in  the  pleura  and  pericardial  sacs.  Patches  of 
ecchymosis  are  frequently  observed  upon  the  skin,  the  mucous  and 
serous  membranes,  and  upon  various  organs  of  the  body.  Small 
hemorrhagic  extravasations  are  frequently  met  with  upon  the  re- 
tina in  the  neighborhood  of  the  optic  disc.  Fatty  degeneration 
of  the  heart  is  most  constant.  The  appearance  of  the  endocar- 
dium is  particularly  striking  ;  it  is  caused  by  degeneration,  and 
from  the  peculiar  mottled  appearance  has  been  called  "  tabby 
mottling."  The  lungs,  as  well  as  the  spleen,  present  no  constant 
pathologic  lesions.  The  liver  is  not  infrequently  enlarged,  pale, 
and  shows  evidences  of  fatty  degeneration.  Many  observers 


346  DISEASES    OF    THE    BLOOD. 

have  attached  special  significance  to  the  condition  of  fatty  de- 
generation and  hypoplasia  of  the  connective  tissues  found  in  the 
stomach,  but  this  condition  may  generally  be  looked  upon  as  a 
result,  rather  than  a  cause,  of  the  disease.  The  pancreas  and 
kidneys  are  usually  softer  and  larger  than  normal  and  show  evi- 
dences of  fatty  degeneration.  Marked  degeneration  has  been 
seen  in  the  posterior  columns  of  the  spinal  cord,  the  cervical 
region  being  most  markedly  affected.  The  disease  is  regarded  as 
a  destruction  of  the  blood,  and  not  as  a  disease  of  the  blood- 
making  organs.  The  destruction  theory  is  upheld  by  the  deposit 
of  pigment  through  the  various  organs  and  the  presence  of  jaun- 
dice and  hemoglobinuria.  The  changes  in  the  bone-marrow  are 
the  substitution  of  red  bone-marrow,  as  in  fetal  bones,  for  fat ; 
the  presence  in  this  marrow  of  a  large  number  of  red  nucleated 
cells  and  megaloblasts  and  also  larger  cells  called  gigantoblasts. 
These  bone-marrow  changes  are  secondary. 

Blood  Changes. — On  puncturing  the  skin,  the  blood  does  not 
flow  freely  and  is  very  thin  and  pale,  though  oftentimes  of  a  dirty 
brown.  On  account  of  its  thinness  it  is  often  difficult  to  get 
enough  to  fill  the  pipet  preparatory  to  counting,  and  after  stand- 
ing for  a  short  time  the  corpuscles  separate  from  the  serum. 
Rouleau  formation  may  be  absent.  Spreading  the  films  is  un- 
satisfactory for  the  same  reason.  The  red  cells  are  decreased  in 
number  in  this  disease  beyond  that  found  in  any  other  condition. 
At  the  first  examination  a  count  of  2,500,000  is  to  be  expected, 
and  a  few  cases  have  been  reported  in  which  only  360,000  red 
corpuscles  existed.  A  count  below  500,000  is  not  very  unusual. 
An  apparent  recovery  sometimes  occurs  during  the  course  of 
treatment,  and  a  case  has  been  reported  in  which  the  count  re- 
turned to  normal.  After  such  a  remission  the  relapse  rapidly 
throws  the  count  down  to  a  very  low  figure.  Hemoglobin  is 
much  reduced,  though  the  color  index  is  often  high.  The  hemo- 
globin may  be  only  1 5  per  cent. 

The  red  cells  show  many  changes  both  in  the  size  and  shape 
of  the  cell.  In  health  about  1 2  per  cent,  of  the  red  cells  meas- 
ure 8-j^j-//,  and  in  this  disease  we  find  megalocytes,  or  giant  cells, 
that  measure  from  8  yz  /J.  to  12  //,  though  these  rarely  constitute 
more  than  1 2  per  cent,  of  the  red  cells.  The  commonest  size  is 
10  fjt.  These  are  only  found  in  health  in  the  new-born  and  under 
pathologic  conditions  in  the  adult.  These  megalocytes  may  be 
oval  or  pyriform.  Microcytes  also  exist,  but  have  no  special 
significance.  The  color  of  the  individual  red  cells  varies  a  good 
deal.  The  megalocytes  are  often  paler  than  the  normal  cells, 
and  the  microcytes  may  take  a  very  deep  stain,  while  others 


PRIMARY    ANEMIAS.  347 

appear  purely  as  shadows  of  cells  in  which  we  see  only  a  faint 
ring  or  a  small  amount  of  granular  matter.  Some,  and  espe- 
cially the  megalocytes,  take  both  stains  (polychromatophilic), 
and  others  show  small  dark  granular  points,  which  condition  is 
known  as  "pinctosis."  Vacuoles  are  found  in  the  protoplasm 
of  these  altered  cells.  All  these  phenomena  are  evidences  of 
degeneration.  The  shape  of  the  cells  is  changed  very  much  : 
they  may  be  pear-shaped,  oval,  star-shaped,  rod-shaped,  lance- 
shaped,  fusiform,  crescentic,  or  kidney-shaped,  constituting  the 
best-marked  example  of  poikilocytosis.  In  fact,  some  specimens 
show  very  few  normal  appearing  cells.  Nucleation  of  the  red 
cells  is  said  to  be  a  common  feature  of  this  disease,  a  fact  that  a 
few  writers  deny.  It  takes  great  patience  and  time  to  determine 
positively  that  this  sign  is  absolute.  Nucleation  may  occur  in  a 
poikilocyte,  in  which  case  it  is  called  a  "  poikiloblast."  It  occurs 
in  cells  of  all  sizes,  so  that  we  find  microblasts,  normoblasts,  and 
megaloblasts.  The  more  megaloblasts  that  one  finds,  the  worse 
is  the  prognosis,  and  especially  so  as  regards  time.  Nuclei  may 
be  found  free  in  the  serum  of  the  blood.  The  red  cell  takes  a 
high  degree  of  stain.  Cabot  puts  the  average  number  of  white 
cells  at  about  4200  ;  the  only  other  change  that  occurs  is  a  rela- 
tive increase  of  the  small  lymphocytes. 

Symptoms. — The  term  "  progressive  pernicious  anemia  "  ex- 
presses the  clinical  conditions  of  the  disease,  which  begins  with 
a  slight  systemic  disturbance,  the  disease  progressing  with  more 
or  less  rapidity  to  a  fatal  termination.  Increasing  languor 
denotes  the  development  of  the  affection.  Oftentimes  there  is 
an  early  rise  of  temperature,  with  marked  irregularities.  Short- 
ness of  breath  and  vertigo  are  constantly  complained  of,  and 
there  is  a  great  tendency  to  attacks  of  syncope.  Toward  the 
end  extreme  weakness  confines  the  patient  to  bed.  The  skin 
presents  a  lemon-yellow  color  and  is  harsh  and  dry.  Palpita- 
tion of  the  heart  is  always  present  and  becomes  extremely 
marked  upon  the  slightest  exertion.  Endocardial  murmurs  are 
rarely  absent,  and  the  apex-beat  is  usually  displaced  consider- 
ably. The  heart-sounds,  although  strong  at  first,  rapidly  be- 
come weak  and  muffled,  showing  evidence  of  fatty  degeneration 
in  the  heart  muscle.  The  pulse  is  short  and  weak,  and  a  venous 
murmur  is  readily  elicited  in  the  vessels  of  the  neck.  Patients 
affected  with  pernicious  anemia  are,  as  a  rule,  flabby,  but  rea- 
sonably well  rounded.  The  bodily  strength  rapidly  decreases, 
showing  marked  muscular  degeneration.  Patches  of  ecchy- 
moses  are  often  observed  on  the  skin  and  mucous  membranes, 
and  edema  of  the  extremities  is  most  constant.  The  appetite 


348  DISEASES    OF    THE    BLOOD. 

is  soon  lost,  and  digestive  disturbances  are  often  present.  As 
the  disease  progresses  hemorrhages  frequently  occur  without 
seeming  provocation,  and  blindness,  due  to  extravasations  near 
the  optic  disc,  has  often  been  observed.  There  are  no  nervous 
symptoms  peculiar  to  this  disease,  those  present  resulting  from 
the  aggravated  condition  of  anemia. 

Diagnosis. — A  careful  history  must  be  elicited  in  a  suspected 
case  of  the  pernicious  forms  of  anemia  in  order  to  exclude 
symptomatic  anemias.  The  peculiar  appearance  of  the  patient 
and  characteristic  changes  in  the  blood,  as  seen  microscopically, 
together  with  the  history  of  the  case,  are,  as  a  rule,  conclusive 
in  making  a  diagnosis.  It  is  not  always,  however,  so  easy  to 
make  a  diagnosis  as  one  would  think  from  reading  the  account 
of  the  characteristic  cases.  The  absence  of  emaciation,  the 
failure  of  iron  to  produce  results,  the  hemorrhages,  the  fever 
occasionally  occurring,  and  the  complexion  of  the  patient  should 
always  be  considered  in  a  difficult  case.  Poikilocytosis  is  not 
associated  with  pernicious  anemia  alone,  but  is  found  in  any 
other  severe  anemia.  The  presence  of  megaloblasts  and  gigan- 
toblasts  is  of  great  weight  when  found  as  favoring  pernicious 
anemia.  In  chlorosis  the  relative  amount  of  hemoglobin  is  de- 
creased, while  in  pernicious  anemia  it  is  proportionately  higher. 
In  the  latter  the  size  of  the  corpuscles  is  usually  larger,  which 
is  not  the  case  in  chlorosis,  though  nucleated  red  cells  and 
poikilocytosis  may  exist.  Rarely  would  secondary  anemia  give 
us  any  trouble.  If  it  should,  it  would  probably  be  in  a  case  of 
malignant  disease,  in  which  case  the  points  already  mentioned 
should  serve  to  distinguish  the  form  of  the  disease  present,  so 
far  as  the  blood  is  concerned. 

Prognosis. — The  prognosis  in  pernicious  anemia  is  extremely 
unfavorable.  At  times  there  are  temporary  improvements,  but  a 
fatal  termination  invariably  occurs,  either  from  the  disease  itself 
or  from  some  intercurrent  affection. 

Treatment. — Of  all  medicinal  agents,  arsenic  has  proved  the 
most  beneficial  in  pernicious  anemia  and  to  a  certain  extent  has 
even  influenced  the  prognosis.  It  is  generally  advised  that  this 
drug  be  given  in  tablets,  or  at  any  rate  alone.  Good  results  have 
been  obtained  from  the  use  of  the  chlorid  of  arsenic,  and  Fowler's 
solution  has  also  been  highly  recommended.  Combinations  of 
iron  and  arsenic  have  sometimes  been  used  with  good  effect,  but 
the  former  drug  is  of  less  use  in  this  form  of  anemia  than  in 
others.  Stimulation  of  the  patient  is  of  great  importance.  Equali- 
zation of  the  blood  pressure  should  be  attempted,  either  by  the 
use  of  intravenous  injections  or  massage.  The  condition  of  the 


PRIMARY    ANEMIAS.  349 

stomach  and  intestines  is  of  the  greatest  importance,  and  great 
care  must  be  used  in  the  administration  of  remedies  that  the 
digestive  apparatus  be  not  disturbed.  The  use  of  bone-marrow 
has  been  tried  in  this  disease,  but  has  not  proved  of  direct  value. 

HODGKIN'S    DISEASE. 
Synonyms. — PSEUDOLEUKEMIA  ;  LYMPHATIC  ANEMIA. 

Definition. — Hodgkin's  disease  consists  of  a  hyperplasia  of 
the  lymphatic  glands,  associated  with  anemia  and  occasional 
lymphoid  growths  in  the  liver,  spleen,  and  other  organs. 

Causes. — The  etiology  is  obscure  ;  it  is  a  disease  of  early  life, 
and  is  more  prevalent  in  males  than  in  females.  Among  those 
diseases  which  are  supposed  to  bear  a  predisposing  influence 
syphilis,  tuberculosis,  malaria,  and  rachitis  may  be  mentioned. 

Pathologic  Anatomy. — There  is  no  pathologic  lesion  that 
distinguishes  Hodgkin's  disease  from  leukocythemia  save  the 
absence  of  leukocytic  infiltration  so  constantly  seen  in  the  latter 
disease.  The  lymphatic  glands  in  all  the  structures  of  the  body 
are  affected.  In  some  instances  one  solitary  gland,  or  different 
groups  of  glands,  may  show  intense  hypertrophy.  Occasionally 
secondary  infection  supervenes  and  suppuration  results.  The 
spleen,  liver,  and  kidneys  are  commonly  enlarged,  the  spleen  being 
especially  so.  The  bone-marrow  shows  degenerative  changes 
and  evidences  of  lymphatic  tissue  formations  are  to  be  seen. 

Blood. — The  blood  shows,  in  the  first  stage  of  the  disease,  no 
appreciable  change  unless  it  be  a  diminution  of  the  red  cells. 
When  the  case  becomes  markedly  anemic,  the  blood  count  may 
fall  to  2,000,000,  and  if  the  anemia  should  continue  severe, 
nucleated  red  cells  are  found.  The  white  corpuscles  are  not  in- 
creased ;  they  may  be  normal,  a  little  under,  or  rarely  a  little 
over,  and  should  any  inflammatory  action  occur  in  the  glands, 
they  are,  of  course,  increased,  and  the  multinucleated  cells  pre- 
dominate. The  hemoglobin  is  decreased  out  of  proportion  to  the 
decrease  of  the  red  cells. 

Symptoms. — A  slowly  developing  anemia  is  the  attending 
phenomenon  marking  the  progress  of  Hodgkin's  disease.  The 
patient  complains  of  headache  from  the  onset ;  vertigo  and  pal- 
pitation are  rarely  absent,  and  a  gradual  increase  of  weakness 
marks  the  progress  of  the  malady.  The  symptom  of  chief  im- 
portance clinically  is  the  enlargement  of  the  lymphatic  glands 
and  of  the  spleen.  As  before  stated,  any  group  of  lymphatics 
may  be  affected,  but  the  submaxillary  and  cervical  glands  are 
most  commonly  involved.  In  many  instances  hypertrophy  of 


35O  DISEASES    OF    THE    BLOOD. 

the  glands  on  one  side  of  the  neck,  followed  by  the  involvement 
of  those  on  the  other  side,  usually  marks  the  beginning  of  an 
attack.  Hemorrhages  are  common,  and  small  patches  of  ecchy- 
mosis  are  scattered  here  and  there  over  the  entire  surface  of  the 
body.  There  is  usually  slight  fever,  but  it  is  decidedly  irregular 
and  is  inclined  to  be  paroxysmal.  At  times  there  is  considerable 
edema  beneath  the  eyes  and  around  the  ankles,  bearing  evidence 
of  cardiac  insufficiency.  The  bowels,  as  a  rule,  are  constipated, 
and  although  the  stomach  is  at  first  retentive,  nausea  and  vomit- 
ing may  later  occur. 

Diagnosis. — Distinction  must  be  made  between  pseudoleu- 
kemia  and  enlarged  tuberculous  glands.  The  negative  results 
of  blood  examination  and  a  tendency  of  the  gland  to  soften  and 
break  down  will  point  to  the  presence  of  tubercular  disease. 
Much  difficulty  is  often  experienced  in  distinguishing  malignant 
tumors  (lymphosarcoma).  The  diagnosis  can  not  always  be 
made,  but  in  many  cases  the  recognition  of  the  slower  and  more 
irregular  growth  of  the  tumor  and  the  involvement  of  the  super- 
ficial tissues  will  point  toward  malignant  disease. 

Prognosis. — The  chances  for  the  arrest  of  pseudoleukemia 
are  exceedingly  meager,  and  the  outlook  is  most  unfavorable. 

Treatment. — Here,  again,  as  in  the  treatment  of  pernicious 
anemia,  arsenic  has  been  found  to  do  the  most  good.  Hygienic 
treatment  should  never  be  neglected,  and  much  benefit  is  often 
effected  by  the  removal  of  the  patient  to  new  surroundings. 
Iron,  phosphorus,  cod-liver  oil,  and  strychnin  have  been  used 
with  benefit  in  the  treatment  of  the  disease.  Preparations  of  the 
glandular  substances  have  a  valuable  place  here  :  Phospho- 
albumin,  bone-marrow  in  fluid  form,  or  tabloids.  These  last 
should  be  gradually  increased  to  do  the  most  good.  Local  ap- 
plications to  the  affected  glands  may  be  practised,  and  in  many 
cases  do  good,  temporarily  at  least.  Surgical  interference  by  the 
removal  of  the  diseased  glands,  although  allowable  in  the  early 
stages  of  the  disease,  has  thus  far  given  negative  results. 

SECONDARY  ANEMIA. 

For  purposes  of  classification  this  term  is  applied  to  those  con- 
ditions of  blood  poverty  not  cytogenic  in  origin. 

The  red  cells  are  diminished  in  severe  cases  and  may  fall  to  a 
very  low  figure.  A  low  blood  count,  however,  is  very  rare.  The 
cells  may  be  paler  than  normal,  may  contain  nucleated  cells 
(normoblasts  and,  very  rarely,  megaloblasts),  or  may  be  reduced 
in  size.  The  hemoglobin  is  decreased,  but  not  constantly.  Some- 


SECONDARY    ANEMIA.  351 

times  its  decrease  is  more  marked  than  the  decrease  of  the  red 
corpuscles  would  indicate.  The  leukocytes  are  usually  increased 
in  number ;  they  may  be  normal  and  very  rarely  decreased,  de- 
pending upon  the  condition  to  which  this  anemia  is  secondary. 
When  there  is  a  leukocytosis,  it  is  due  to  an  increase  in  the  neu- 
trophiles. 

In  malignant  disease  a  very  severe  leukocytosis  is  found  at 
times.  Sarcoma  in  childhood  is  an  exception,  the  average  leuko- 
cytosis in  this  disease  being  about  16,000.  The  red  cells  show 
no  changes  except  late  in  the  disease.  After  any  hemorrhage 
there  is  a  change  in  the  blood  depending  upon  the  amount  of 
blood  lost  and  the  character  of  the  case.  Soon  after  the  hem- 
orrhage has  taken  place  and  a  drop  of  blood  is  withdrawn,  the 
number  of  red  blood-corpuscles  in  the  individual  specimen  does 
not  show  a  material  decrease,  for  at  this  time  there  is  only  a  dim- 
inution in  the  quantity  of  the  blood,  but  as  soon  as  serum  has 
been  withdrawn  from  the  tissues  to  attempt  to  make  up  the  blood 
volume,  we  find  a  diminution  of  the  red  cells  to  a  cubic  milli- 
meter on  account  of  the  dilution  of  the  blood.  The  hemoglobin, 
too,  decreases.  Changes  in  the  red  cells  are  a  diminution  in 
size,  color,  occasionally  poikilocytosis,  and  a  nucleation  of  the 
red  cells.  There  is  marked  increase  of  white  cells,  the  neutro- 
philes  predominating.  The  blood  presents  no  characteristic 
changes,  if  any,  in  hemorrhagic  diseases ;  in  hemophilia  the 
blood  withstands  the  effects  of  hemorrhages  better  than  in  other 
conditions.  In  scurvy  there  is  a  diminution  of  red  corpuscles 
and  a  decrease  of  hemoglobin  out  of  proportion  to  the  decrease 
in  the  red  cells,  and  a  moderate  increase  of  leukocytes.  In  ad- 
vanced cases  there  may  be  nucleated  red  cells,  polychromato- 
philia,  and  poikilocytosis. 

Symptoms. — The  characteristic  pallor  of  the  skin  and  mucous 
membranes  will  give  evidence  of  the  patient's  general  condition. 
The  pulse  is  soft,  full,  and  rapid.  Hemic  murmurs  are  often 
present,  and  may  be  heard  in  the  vessels  of  the  neck  and  at  the 
base  of  the  heart.  The  heart  is  frequently  enlarged,  later  becom- 
ing dilated.  Palpitation  is  constantly  present  and  in  cases  of  even 
moderate  severity.  Pulsation  of  the  cervical  vessels  is  often  seen. 
Edema  of  the  feet,  especially  at  the  latter  end  of  the  day  or  at 
night,  may  occur.  The  skin  is  harsh  and  dry,  but  at  times  per- 
spiration has  been  observed.  In  severe  cases  febrile  paroxysms 
and  ecchymoses  occasionally  arise,  and  attacks  of  syncope  give 
evidence  of  the  deficiencies  in  the  cerebral  circulation.  Very  fre- 
quently the  hands  and  feet  are  cold ;  vertigo  and  ringing  in  the 
ears  may  be  present  as  evidences  of  marked  circulatory  distur- 


352  DISEASES    OF    THE    BLOOD. 

bance.  The  digestion  is  weak  and  the  appetite  capricious.  In 
some  cases  there  may  occur  respiratory  changes,  the  breathing 
becoming  hard.  A  resonant  dry  cough  constitutes  a  trouble- 
some feature.  Among  the  nervous  symptoms  of  this  condition 
headache,  disturbed  sleep,  and  neuralgic  pain  are  those  most 
commonly  complained  of.  Emaciation  is  more  or  less  marked, 
and  the  patient  seems  or  feels  depressed.  There  is  a  general 
lack  of  vitality,  this  finding  expression  in  the  whole  appearance 
of  the  patient. 

Prognosis. — The  prognosis  depends  upon  the  cause.  Symp- 
tomatic anemia  is  generally  amenable  to  treatment,  save  in  cases 
of  tuberculosis  and  neoplasm.  When  syncope  is  frequent  and 
prolonged,  the  outlook  is  not  so  promising. 

Diagnosis. — It  is  often  difficult  to  separate  symptomatic  from 
essential  anemia.  A  careful  inquiry  into  the  patient's  general 
history  and  a  thorough  microscopic  examination  of  the  blood  will 
aid  us  in  this  differentiation. 

Treatment. — The  original  source  of  the  anemia  must  be 
sought  for  and  treated.  In  children  the  regulation  of  the  diet 
and  care  of  the  intestinal  tract  often  work  miracles,  for  upon 
these  most  anemias  depend.  The  anemia  following  hemorrhage 
requires  prompt  and  energetic  measures.  Cardiac  stimulants, 
such  as  ammonia,  strychnin,  alcohol,  and  camphor,  must  be  used. 
To  maintain  the  blood  pressure  where  the  depletion  has  been 
great,  intravenous  or  subdermal  injections  or  rectal  irrigations 
are  invaluable.  For  intravenous  injections  Osier  recommends 
the  use  of  the  following  : 

Distilled  water, 1000  parts 

Sodium  chlorid, 5  Par*s 

Sodium  hydroxid, I  part 

Sodium  sulphate, 25  parts. 

This  should  be  given  to  the  patient  in  a  horizontal  position, 
the  head  being  low  and  the  limbs  bandaged.  Other  diseases 
must  be  treated  according  to  the  various  indications.  For  the 
existing  anemia  a  soluble  form  of  iron  should  be  given  internally 
and  arsenic  may  be  used  in  combination  with  advantage.  Above 
all,  open  air,  sunlight,  and  a  good  supply  of  digestible  food  are 
essential  in  any  plan  of  treatment. 

Tubercular  Diseases. — In  tubercular  disease  there  is  no  increase 
in  the  white  cells.  This  seems  to  be  true  of  all  forms  of  tuber- 
culosis, at  any  rate  for  a  time.  A  leukocytosis  appears  when 
cavity  formation  occurs  in  the  lungs,  but  not  with  a  simple  tuber- 


SECONDARY    ANEMIA.  353 

cular  deposit.  So  long  as  tubercular  glands  and  tubercular  de- 
posits are  simple — that  is,  there  is  no  mixed  infection — no  leuko- 
cytosis  is  found,  but  when  the  infections  become  mixed,  it  will  at 
once  appear.  Cases  of  tubercular  meningitis  have  of  late  been 
reported  in  which  leukocytosis  has  been  found,  though  it  is  pos- 
sible that  some  other  element  may  have  entered  into  the  con- 
dition. Rotch  reports  an  increase  of  white  cells  in  a  child  dying 
of  miliary  tuberculosis.  The  red  cells  are  affected  according  to 
the  degree  of  anemia. 

Inherited  syphilis  presents  a  diminution  of  red  cells  and  a 
marked  leukocytosis.  Rickets  or  rachitis  presents  the  same  con- 
dition. 

The  Blood  as  a  Guide  in  the  Diagnosis  of  Appendicitis. — The 
examination  of  the  blood  is  of  vast  importance  in  the  diagnosis 
as  well  as  in  the  treatment  of  appendicitis.  Following  the  well- 
known  relationship  of  infection,  pus-formation,  and  leukocytosis, 
the  accompanying  facts  will  be  found  of  practical  value.  In 
simple  catarrhal  appendicitis  the  increase  of  the  white  cells  is 
slight.  Should  there  be  an  increasing  leukocytosis  during  the 
course  of  the  disease,  it  would  be  safe  to  assume  that  the  germs 
had  penetrated  into  the  body  of  the  organ,  and  that  the  peri- 
toneal side  of  the  appendix  was  becoming  involved,  and  pus  was 
forming,  demanding  operative  procedures.  With  perforation  of 
the  appendix  and  in  the  fulminating  type  there  is  marked  leuko- 
cytosis. 

The  blood  count  is  useful  as  an  indication  for  treatment,  and 
the  presence  of  a  leukocytosis  with  pain  and  tenderness  in  the 
right  iliac  fossa  and  rigid  abdominal  muscles  should  always  de- 
mand an  immediate  operation,  and  a  case  showing  no  leukocy- 
tosis could  more  safely  be  postponed  until  after  the  acute  stage 
might  pass.  Watching  it  carefully,  however,  by  daily  blood 
counts,  would  keep  us  safely  posted. 

Blood  in  Pneumonia. — In  pneumonia  the  blood  presents  a  large 
amount  of  fibrin.  There  are  no  special  changes  in  the  red  blood- 
corpuscles,  nor  is  there  a  very  pronounced  anemia  after  the  dis- 
ease has  run  its  course.  The  leukocytosis  of  pneumonia  has 
been  very  carefully  studied,  and  the  following  facts  ascertained  : 
if  the  infection  be  mild  and  the  patient  strong,  it  is  slight ;  if 
severe  and  the  patient  reacts  faintly,  there  is  no  leukocytosis  and 
the  result  is  fatal  ;  with  a  severe  infection  and  a  vigorous  reaction 
the  leukocytosis  is  very  marked  and  the  prognosis  is  guardedly 
favorable. 


354 


DISEASES    OF    THE    BLOOD. 


The  following  table,  prepared  by  Caspar  Sharpless,  will  assist 
in  the  differentiation  of  diseases  : 


DISEASE. 

LEUKOCY- 

TOSIS. 

LYMPHO- 
CYTES. 

NEUTRO- 

PHILKS. 

RED 
CELLS. 

HEMO- 
GLOBIN. 

Typhoid  fever,     .    . 

Absent 

Relatively 

Decreased 

Decreased 

Proportionate- 

increased 

ly  decreased 

Typhoid    with    com- 

plications,     .    .    . 

Present 

Increased 

Decreased 

Proportionate- 

ly decreased 

Scarlet  fever     .    .    . 

Present 

Decreased 

Increased 

Decreased 

Proportionate- 

ly decreased 

Absent 

No  change 

No  change 

Smallpox,      .... 

Marked  on 

Increased 

Much   de- 

o 

Proportionate- 

third day 

creased 

ly  decreased 

Erysipelas,    .... 

Marked 

Increased 

Decreased 

Proportionate- 

ly decreased 

Diphtheria,  .... 

" 

Rarely 

Increased 

Slight  de- 

Proportionate- 

increased 

crease 

ly  decreased 

Influenza,      .... 

No  change 

No  change 

No  change 

Typhus  fever,  .    .    . 

«        « 

"        " 

«       « 

Follicular  tonsillitis, 

Moderate 

«        « 

Acute  rheumatism,  . 

ti 

Increased 

Markedly 

Markedly   de- 

decreased 

creased 

Septicemia,  .... 

Marked 

Increased 

Markedly 

Proportionate- 

decreased 

ly  decreased 

Abscess,    

« 

Increased 

Decreased 

Proportionate- 

ly decreased 

Meningitis,    .... 

" 

Increased 

Slightly  de- 

Proportionate- 

creased 

ly  decreased 

Peritonitis,    .... 

« 

Increased 

Slightly  de- 

Proportionate- 

creased 

ly  decreased 

Pericarditis  

« 

Increased 

Slightly  de- 

Proportionate- 

creased 

ly  decreased 

Pleurisy,    

« 

Increased 

Slightly  de- 

Proportionate- 

creased 

ly  decreased 

Malaria,     

Absent 

Relatively 

Decreased 

Decreased 

Proportionate- 

increased 

ly  decreased 

Pneumonia    .... 

Marked 

Decreased 

Increased 

Decreased 

Proportionate- 

ly decreased 

In  pneumonia  there  is  a  decrease  of  the  eosinophiles  and  in 
scarlet  fever  an  increase. 


CHAPTER  XI. 
CONSTITUTIONAL  DISEASES. 


RHEUMATIC  FEVER. 

Synonyms. — ACUTE  RHEUMATISM  ;  ACUTE  ARTICULAR  RHEUMA- 
TISM ;  INFLAMMATORY  RHEUMATISM. 

Acute  rheumatism,  or  rheumatic  fever,  is  an  acute  infectious 
but  noncontagious  disease,  depending  upon  some  unknown  in- 
fective agency,  and  characterized  by  a  wide-spread  inflammation 
of  the  joints  with  a  peculiar  tendency  to  affect  the  heart.  In 
children  the  serous  membranes  are  more  likely  to  become  in- 
volved than  the  articulations.  As  seen  in  early  life  it  is  usually 
subacute. 

Causes. — The  cause  of  rheumatism  is  not  yet  understood, 
but  is  explained  by  one  of  three  theories  :  (i)  That  it  de- 
pends upon  a  morbid  entity,  the  result  of  defective  assimila- 
tion, the  product  of  which  is  lactic  acid,  or  certain  combinations 
of  it ;  (2)  the  nervous  theory,  according  to  which  either  the 
nerve  centers  are  primarily  affected  by  cold  and  the  local  lesions 
are  atrophic  in  character,  or  that  this  nervous  disturbance  brings 
about  hurtful  metabolism,  so  that  the  nitrogenous  products, 
instead  of  being  converted  into  urea,  are  transformed  into  uric 
acid  and  other  poisonous  products  which  cause  the  symptoms  ; 
(3)  the  germ  theory,  claiming  a  specific  microbe  as  the  cause  of 
the  joint  inflammation,  the  analogy  of  which  is  well  marked  in 
the  septic  processes,  gonorrhea,  and  scarlet  fever.*  Heredity 
has  an  important  relationship  to  cause  in  two-thirds  of  the  cases. 
Whatever  be  the  poison,  it  has  a  selective  tendency  for  fibrous 
and  serous  tissues.  The  immediate  cause  is  rapid  cooling  of  the 
surface,  in  most  instances,  or  changes  in  the  weather  beyond  our 
ordinary  means  of  recognition.  It  is  essentially  a  disorder  of 

*  Various  observers  have  recently  studied  the  subject,  notably  Herman  Sahli, 
Leyden,  Achalme,  Riva,  Triboulet  and  Coyon,  Singer,  Jaccoud,  and  others. 
Achalme's  bacillus,  an  anaerobic,  more  or  less  motile  rod,  like  the  anthrax  bacillus, 
is  shown  to  produce  symptoms  of  rheumatism. 

355 


356  CONSTITUTIONAL    DISEASES. 

young  people  and  relatively  common  in  children,  although  many 
of  the  cases  described  in  infancy  belong  to  a  different  affection, 
the  arthritis  of  sucklings.  In  the  young  a  potent  cause  is  pre- 
disposition or  inheritance.  The  inheritance  is  frequently  from  a 
gouty  parent.  Children  under  five  years  are  readily  affected, 
and  instances  are  recorded  in  babes  of  one  and  two  years.  By 
far  the  larger  number  of  cases  arise  in  the  spring,  and  one  attack 
predisposes  to  another. 

Tonsillitis  often  occurs  as  a  precursor  to  rheumatism  or  acute 
arthritis,  and  it  is  undoubtedly  occasionally  followed  by  acute 
endocarditis.  Packard  regards  these  cases  of  endocardial  inflam- 
mation which  follow  tonsillitis  as  cases  of  irritation  of  serous 
surfaces  by  germs  or  their  toxins  entering  the  circulation  from 
the  inflamed  tonsils.  Acute  rheumatism  may  not  be  due  to  any 
one  specific  organism,  but  rather  a  form  of  septic  intoxication  or 
septic  infection  due  to  the  absorption  of  the  products  of  several 
species  of  micro-organisms  or  the  absorption  of  the  germs  them- 
selves in  some  cases. 

Morbid  Anatomy. — The  synovial  membranes  of  the  joints 
and  ligaments  become  injected,  and  effusion  of  a  turbid  fluid 
takes  place  into  them  and  the  surrounding  tissues.  Minute 
hemorrhages  into  the  membranes  are  seen.  The  cartilages  of 
the  joints  are  roughened  and  swollen,  but  rarely  suppurate. 
A  nodular  periostitis  has  been  described.  The  blood  shows 
diminution  of  the  red  blood-corpuscles  and  an  excess  of  fibrin. 
Into  both  the  endocardium  and  pericardium  inflammatory  lesions 
may  arise,  with  much  plastic  exudation.  Fibrinous  coagula  are 
found  in  the  heart  and  great  vessels.  Secondary  inflammations, 
such  as  pericarditis  and  pneumonia,  are  often  noticed.  Pleurisy, 
with  or  without  effusion,  frequently  occurs. 

It  has  been  shown,  both  from  clinical  symptoms  and  morbid 
anatomy,  that  the  essential  structures  of  the  heart  may  be  seri- 
ously and  permanently  altered  by  disease  of  rheumatic  origin 
without  evidence  being  found  of  painful  states. 

Symptoms. — In  children  the  joint  affection  is  less  marked 
than  in  adults  and  is  limited  to  fewer  articulations.  When  pres- 
ent, it  generally  involves  the  ankles  and  wrists,  and  there  is 
more  likely  to  be  tenderness  rather  than  swelling.  Tender, 
painful,  or  stiff  joints  in  children  should  lead  to  a  study  of  the 
temperature  and  the  urine.  The  fever  does  not  continue  long 
or  reach  a  very  high  degree.  Delirium  is  uncommon.  Should  the 
fever  become  very  great  or  prolonged,  delirium  may  be  present, 
and  pericarditis  should  be  suspected.  The  urine  is  concen- 
trated, highly  colored,  and  scanty,  the  skin  moist,  but  rarely 


RHEUMATIC    FEVER.  357 

is  there  such  profuse  sweating  as  in  adults.  The  greatest  danger 
is  due  to  heart  involvement,  which  is  much  more  frequent  than 
in  older  folk.  Endocarditis  is  the  commonest,  and  arises  in  the 
majority  of  cases — if  not  in  the  first,  then  in  later  attacks.  The 
symptoms  of  this  complication  are  disturbances  of  breathing,  a 
slight  cough,  possibly  pain  or  discomfort  in  the  region  of  the 
heart,  and  finally  a  murmur  is  heard,  generally  at  or  near  the 
apex,  occurring  with  the  systole.  An  accentuated  second  sound 
may  follow  the  mitral  murmur,  or  occasionally  is  heard  in  the 
aorta.  More  rarely  there  is  a  diastolic  aortic  murmur  or  a  dias- 
tolic  or  presystolic  mitral  murmur.  The  impulse  is  more  or  less 
increased  in  force  and  extent,  but  it  is  very  difficult  to  ascertain 
whether  there  is  increased  dullness  on  percussion.  The  pulse 
is  seldom  regular,  and  usually  of  higher  tension  than  normal. 
Congestive  states  of  the  lung  are  liable  to  arise,  slight  dullness 
being  elicited,  and  fine  rales  may  be  heard,  and  along  with  these 
signs  of  increasing  irregularities  of  the  circulation.  Ulcerative 
endocarditis,  when  it  occurs,  is  ushered  in  by  chills,  high  tem- 
perature, and  profuse  sweats.  The  danger  arises  here  of  the 
detachment  of  vegetations,  which,  carried  into  the  vessels  of  the 
brain  or  elsewhere,  produce  cerebral  plugging  or  other  embolic 
troubles.  The  first  sound  of  the  heart  may  become  merely  muffled 
or  impaired  enough  to  cause  anxiety  and  finally  pass  away. 
This  may  be  due  merely  to  hyperemia  altering  the  heart- 
sounds,  which  subsides  with  the  systemic  inflammation.  It  must 
ever  be  conscientiously  borne  in  mind  that  in  spite  of  all  recog- 
nizable adventitious  heart-sounds  an  endocarditis  can  be  present 
during  the  progress  of  rheumatism,  with  or  without  painful  states, 
working  serious  damage,  or  at  any  moment  latent  disturbances 
may  become  apparent.  The  temperature  ranges  from  about 
101°  to  101.5°  F.  (38.3°  to  38.5°  C). 

Pericarditis  is  not  so  common  in  children  as  in  adults,  and  is 
rare  under  seven  years  of  age.  The  existence  of  this  is  more  dif- 
ficult of  recognition  than  the  endocardial  lesions,  though  they 
may  coexist.  The  symptoms  of  a  beginning  pericarditis  are  most 
varied  in  character  and  degree.  They  may  be  so  trivial  as  to 
pass  unnoticed,  or  cause  horrible  distress.  The  pain  and  severe 
dyspnea  are  probably  the  result  of  the  involvement  of  the  super- 
pericardial  nerves,  as  has  been  demonstrated  by  Sansom.  This 
author  also  says  there  is  a  swollen  heart  in  rheumatism  which  is 
not  due  to  pericarditis,  but  to  congestion  and  infiltration  of  the 
whole  heart  muscle,  and  that  this  is  not  a  myocarditis.  The 
symptoms  are  those  of  endocarditis,  with  an  exaggeration  of  the 
distress  and  dyspnea,  more  evidences  of  nervous  perturbation, 


358  CONSTITUTIONAL    DISEASES. 

more  fever,  and  more  pain  about  the  heart.  It  is  much  less 
easy  to  outline  cardiac  dullness  in  children  than  in  adults,  and 
very  often  this  is  of  irregular  shape.  Auscultatory  percussion, 
with  or  without  the  phonendoscope,  makes  this  more  exact. 
The  form  common  in  children  is  a  dry  pericarditis,  or,  at  least, 
the  effusion  is  not  usually  great.  Friction  sounds  may  be  heard. 
Sometimes  this  complication  precedes  the  arthritis,  but  it  may 
occur  in  any  stage  of  rheumatism,  and  is  liable  to  show  itself 
anew  as  different  joints  become  affected.  Sir  R.  D.  Powell  is 
of  the  opinion  that  the  more  dangerous  heart  lesions,  mitral 
stenosis  and  aortic  regurgitation,  rarely  occur  in  primary  attacks, 
but  are  the  results  of  slow  deforming  valvulitis.  Pneumonia 
is  an  uncommon  complication,  and  when  present,  is  not  so  much 
shown  by  cough  and  expectoration  as  by  localized  dullness  and 
sudden  increase  of  temperature.  Pleurisy,  single  or  double,  is  of 
frequent  occurrence.  When  single,  it  is  liable  to  be  of  the  left  side 
and  thus  imperil  the  pericardium.  Chorea,  which  is  very  closely 
allied  to  rheumatism  in  childhood,  generally  shows  itself,  if  at  all, 
toward  the  end  of  an  attack,  upon  the  subsidence  of  the  more  acute 
symptoms.  Chorea  may  begin  at  the  height  of  the  rheumatic 
process,  and  when  it  does,  there  has  probably  been  a  beginning  of 
cardiac  involvement,  and  it  is  most  likely  to  arise  in  nervous,  emo- 
tional children.  Rheumatic  children  are  frequently  attacked  with 
an  acute  tonsillitis,  appearing  much  like  diphtheria  or  the  throat 
inflammation  of  scarlatina  or  influenza.  This  pharyngitis  may  be 
the  first  symptom  of  rheumatism,  or  it  may  occur  in  its  course, 
and  is  rarely  followed  by  suppuration  or  ulceration.  Fibrous 
nodules  to  be  found  about  the  joints  are  sometimes  described  by 
foreign  authors  ;  these  are  tender  on  pressure,  about  the  size  of 
a  shot  or  a  pea,  recognized  by  touch,  and  occasionally  insensi- 
tive. These  have  some  relation  to  endocarditis,  and,  where  fre- 
quently occurring,  are  said  to  be  an  index  of  cardiac  involvement. 
A  common  sequel  of  rheumatism  is  anemia,  which  may  be  very 
marked  and  persistent.  Successive  rheumatic  attacks  induce 
blood  dyscrasia,  a  lowering  of  all  the  vital  forces,  shown  in 
peevishness  and  general  discomfort.  The  evil  effect  of  rheuma- 
tism on  the  blood  resembles  that  of  the  malarial  poison.  Certain 
diseases  are  definitely  connected  with  the  rheumatic  diathesis,  as 
erythema  of  the  various  forms  and  purpura.  Muscular  rheuma- 
tism is  also  seen  in  children,  especially  in  the  form  of  torticollis. 
Diagnosis. — In  the  rheumatism  of  children,  as  has  been 
pointed  out,  arthritis  is  relatively  mild,  the  cardiac  symptoms 
most  severe  ;  the  joints  may  present  little  more  than  a  stiffening, 
with  tenderness  upon  pressure  or  upon  active  or  passive  move- 


RHEUMATIC    FEVER.  359 

ment.  In  them  acid  sweats  and  pyrexia  are  less  prominent ;  the 
hemorrhage  and  vasomotor  phenomena,  purpura,  erythema,  also 
pleurisy  are  more  in  evidence.  In  children  various  phases  of 
rheumatism  may  arise  independent  of  one  another.  The  diag- 
nosis will  need  corroboration  by  estimating  family  tendencies, 
such  as  recurring  attacks  of  tonsillitis  or  a  history  of  rheumatic 
seizures.  If  the  heart  be  found  affected  or  the  characteristic 
nodules  or  erythema  be  seen,  or  a  history  is  furnished  of  ante- 
cedent chorea,  along  with  multiple  painful  involvement  of  the 
joints,  fever,  and  sweating,  then  we  may  be  sure  of  our  diagno- 
sis. The  heart  must  be  watched  unceasingly,  and  often  gives 
little  evidence  of  a  growing  damage.  The  symptoms  of  scarla- 
tinal arthritis  are  so  like  those  of  rheumatism  as  to  be  indistin- 
guishable from  it  unless  there  be  some  guiding  symptoms. 

In  epidemic  cerebrospinal  meningitis  the  joints  sometimes 
become  so  tender  as  to  be  mistaken  for  acute  rheumatism.  Vio- 
lent headache,  spasm  of  the  neck  muscles,  the  spots  common  in 
cerebrospinal  fever,  will  act  as  sufficient  differentiation.  There 
are  many  conditions  arising  in  children,  accompanied  by  tender- 
ness of  the  joints,  which  should  be  borne  in  mind  ;  among  these 
are  pyemia,  scurvy,  the  tender  joints  of  rickets,  some  conditions 
of  syphilis,  scrofulous  arthritis,  and  the  pyemic  arthritis  of  infants. 

Course  and  Duration. — The  complications  of  rheumatic  fever 
in  children  influence  largely  its  progress  and  curability.  The 
duration  varies  from  ten  days  to  three  weeks  in  the  well-estab- 
lished cases,  and  may  be  marked  even  then  with  fresh  outbreaks 
of  varying  severity.  If  treatment  is  instituted  at  once  and  absolute 
rest  maintained,  a  much  earlier  recovery  may  be  expected.  If 
the  heart  becomes  affected,  the  course  of  the  malady  is  prolonged. 
A  dangerous  condition,  especially  to  the  heart,  is  a  series  of  sub- 
acute  attacks,  following  upon  one  another,  while  the  joints  are 
little  disturbed.  Cases  in  very  young  children  have  been  re- 
ported where  recovery  took  place  in  a  few  days. 

Prognosis. — The  danger  of  rheumatism  depends  rather  upon 
cardiac  implication  than  upon  the  fever  itself.  When  attacks  are 
frequently  repeated,  this  is  likely  to  occur  and  grow  worse  with 
each  outbreak.  In  rare  instances  the  heart  may  escape  after 
many  attacks.  It  is  extremely  difficult  to  estimate  the  amount 
of  cardiac  mischief  that  remains  after  the  acute  symptoms  have 
subsided.  A  mere  roughening  of  the  valve  may  disappear  after 
a  few  months,  but  is  likely  to  remain  and  give  evidence  by 
hypertrophy  with  dilatation.  This  is  especially  to  be  feared  with 
slight  recurrences  of  rheumatism,  and  above  all  should  a  sharp 
attack  arise.  Few  cases  of  endocarditis  are  unaccompanied  by 


360  CONSTITUTIONAL    DISEASES. 

involvement  of  the  pericardium  also.  Pericarditis  may  occur  by 
itself,  and  from  it  recovery  is  more  hopeful.  The  hypertrophy 
or  dilatation  is  established  more  readily,  in  children  than  in 
adults,  and  increases  at  a  higher  rate.  The  appearance  of  fibrous 
nodules  is  a  danger-signal.  Marked  anemia  following  heart  dis- 
turbance is  a  grave  feature. 

Treatment. — Immediately  on  the  appearance  of  rheumatism 
the  child  must  be  put  to  bed  and  clothed  in  woolen  or  silken 
garments,  and  lie  between  soft,  thin  blankets.  If  the  fever  be 
high  and  the  sweat  not  profuse,  it  is  not  well  to  keep  the  room 
very  hot,  but  it  should  be  dry.  No  movements  should  be  allowed, 
and  the  earlier  medication  directed  to  the  securing  of  tranquillity. 
If  pain  be  not  very  great,  this  is  difficult,  but  is  most  essential. 
The  bowels  must  be  promptly  relieved  by  a  saline  or  other  laxa- 
tive. All  dejecta  must  be  passed  into  the  bed-pan,  which  should 
be  well  warmed  ;  the  upright  posture  can  under  no  circum- 
stances be  allowed  until  all  danger  is  quite  gone. 

No  definite  amusement  should  be  supplied  ;  monotony  is  best, 
and  children  will  more  readily  submit  to  this  than  adults.  The 
tender  joints  require  protection  at  all  times,  and  among  the  best 
is  simple  cotton-wool  kept  in  place  by  a  few  light  turns  of  a 
bandage.  If  these  parts  are  very  painful,  wet  applications,  such 
as  solutions  of  bicarbonate  of  soda  and  laudanum  or  salicylate 
of  methyl  or  witch-hazel,  may  relieve  them.  The  fixation  of 
the  limbs  by  means  of  light  splints,  such  as  light  but  stiff  pieces 
of  cardboard,  either  straight  or  molded  to  fit,  is  very  comforting. 
Cold  applications  will  relieve  heat  and  pain — ice  or  iced  water, 
frequently  changed.  Nervous  or  anemic  children  prefer  hot  and 
dry  applications.  To  the  water  thus  applied  various  substances 
may  be  added,  such  as  chloroform  water  or  mint  water,  or  these 
together  with  a  little  carbolic  acid  and  bicarbonate  of  soda.  The 
blood  in  rheumatism  has  less  than  its  normal  alkalinity,  or,  as 
has  been  practically  demonstrated,  becomes  actually  acid.  This, 
then,  warrants  the  use  of  alkaline  salts  throughout  the  course 
of  the  disease,  no  matter  what  other  medicaments  are  used  ;  it 
also  is  necessary  to  consider  defective  elimination  from  the  blood. 
The  remedies  of  most  use  are  those  which  exert  a  preservative 
or  antiseptic  action  on  the  tissues  (Foster) — methyl  salicylate, 
potassium  iodid,  potassium  bicarbonate,  iron  chlorid,  quinin,  etc. 

All  medicines,  moreover,  should  be  in  large  dilution  and  the 
patient  be  encouraged  to  drink  freely  of  the  natural  alkaline 
waters,  such  as  Seltzer  and  Vichy.  The  use  of  internal  medi- 
cines for  the  rheumatic  fever  is  not  very  satisfactory.  The  com- 
pounds of  salicylic  acid  are  of  value  to  relieve  pain,  but  can  not 


RHEUMATIC    FEVER.  361 

be  shown  materially  to  shorten  the  disease  or  prevent  endocar- 
ditis. The  salicylate  of  sodium  is  the  best  for  its  antirheumatic 
and  antipyretic  action,  but  it  often  disturbs  the  stomach.  The 
salicylate  of  ammonium  is  useful  along  with  the  liquor  ammonii 
acetatis.  The  salicylate  of  strontium  and  of  cinchonidin  has 
been  lauded  by  some,  as  has  also  the  salicylate  of  lithium — this 
last  more  particularly  for  the  subacute  varieties.  Cheadle  pre- 
fers salicin  alone  or  with  sodium  or  potassium  citrate.  Sansom 
continues  the  salicylates  from  three  to  six  weeks,  and  gives  along 
with  this  preparations  of  ammonia — the  carbonate  or  the  aromatic 
spirits  of  ammonia.  The  salicylates  should  be  given  in  full  doses 
of  from  three  to  fifteen  grains,  every  four  .hours,  for  three  or  four 
days,  when,  if  they  have  failed  to  relieve,  they  are  of  little  more 
use  ;  if  they  have  relieved,  at  the  end  of  this  time  they  may  be 
lessened  one-half  for,  perhaps,  a  week  longer.  Failing  relief 
from  these,  we  may  succeed  with  a  cautious  dose  or  two  of  coal- 
tar  antipyretics,  which  are  liable  to  depress  the  heart,  and  it  is 
well  to  guard  them  with  a  little  strychnin,  digitalis,  or  strophan- 
thus.  It  is  useful  to  combine  the  iodids  of  potassium  or  sodium 
with  either  of  the  foregoing  group,  especially  after  the  first  few 
days.  If  the  fever  runs  high  and  a  failure  of  respiratory  vigor, 
delirium,  or  other  cerebral  symptoms  appears,  prompt  and  vigor- 
ous antipyresis  should  be  employed ;  here  the  cool  (80°  F. 
—26.7°  C.)  or  cold  (60°  to  50°  F.— 15.6°  to  10°  C.)  pack  is 
valuable,  with  a  few  well-directed  doses  of  acetanilid  or  antipyrin, 
carefully  watched.  To  secure  tranquillity  of  mind  and  body 
the  bromids  are  useful,  though  depressing  :  especially  useful  are 
the  bromids  of  lithium,  sodium,  or  strontium.  Few  things  are 
better  here  than  small  doses  of  opium,  such  as  the  elixir  of 
McMunn,  Dover's  powder,  or  codein,  especially  if  cerebral  in- 
volvement be  suspected.  Quinin  or  the  salicylate  of  cinchonidin 
sometimes  acts  most  happily  as  an  auxiliary  measure,  especially 
when  the  temperature  attempts  to  run  high,  which  is  likely  to 
be  the  case  where  there  is  endocarditis  or  pericarditis.  Five  to 
eight  grains  a  day  should  be  given  to  a  child  five  years  old. 
For  the  heart  complications  full  doses  of  opium  with  or  without 
brandy  or  whisky  are  recommended  by  DaCosta,  Powell,  and 
Cheadle.  When  exudations  arise,  as  in  the  pleura  or  pericar- 
dium, the  iodids  are  especially  valuable.  For  imminent  heart 
failure,  shown  by  a  feeble  first  sound,  small  and  irregular  pulse, 
the  hypodermic  use  of  strychnin  with  brandy  and  digitalis  is 
urged  by  Cheadle.  It  is  well  to  avoid  the  use  of  syrups  as 
menstrua,  because  of  their  tendency  to  produce  acid  in  the 
stomach,  and  use  rather  a  few  drops  of  compound  tincture  of 


362  CONSTITUTIONAL    DISEASES. 

cardamom,  which,  with  the  alkalies,  make  a  sweetish  mixture, 
with  or  without  a  little  glycerin.  Simple  elixir  or  essence  of 
pepsin  also  answers  very  nicely. 

Preventive  treatment  is  exceedingly  important  and  has  large 
possibilities.  Children  of  rheumatic  parents,  or  who  have  had 
threatenings  or  mild  attacks,  should  have  the  utmost  attention 
given  to  the  hygiene  of  their  skin,  and  become  accustomed  to 
regular  cool  or  cold  bathings.  Nothing  is  more  valuable  than 
this  ;  after  the  bath  the  skin  should  be  thoroughly  rubbed,  and, 
if  not  too  tender,  with  a  fairly  rough  towel,  or  a  towel  dipped  in 
brine,  rough  dried,  and  kept  for  the  purpose.  If  the  skin  be  a 
leaky  one,  a  little  diluted  alcohol,  or  spirits  of  camphor  or  aro- 
matic vinegar,  may  be  applied.  The  skin  must  be  promptly  pro- 
tected by  clothing  immediately  after  the  bath  and  at  all  other 
times.  After  exercise  or  overheating,  children  susceptible  to  rheu- 
matic attacks  should  be  dry  rubbed  in  a  warm  room  and  redressed. 
All  growing  pains  or  joint  tenderness  must  be  watched  sedu- 
lously and  considered.  Such  children  should  never  be  too  warmly 
clothed,  except  possibly  as  to  their  underwear,  and  should  never 
be  allowed  to  have  their  knees,  shoulders,  or  arms  left  bare  or 
their  feet  carelessly  wetted.  Indeed,  it  is  distinctly  important  for 
children  susceptible  to  rheumatism  to  live  in  a  dry  climate,  cer- 
tainly in  winter. 

The  diet  is  of  importance  and  had  better  be  nitrogenous,  and 
not  include  too  much  of  starch.  Milk  is  the  best  food.  General 
tonics  are  needed  for  the  repair  of  the  blood  dyscrasia,  especially 
iron  and  cod-liver  oil. 

Gonorrheal  articular  rheumatism  is  rare  in  children,  but  when 
it  does  occur,  it  is  mostly  confined  to  one  or  a  few  joints.  The 
effusion  may  be  large  and  become  purulent.  This  must  be 
promptly  treated  to  save  the  joint  and  to  protect  from  pyemic 
infection.  The  treatment  is  surgical — an  aseptic  opening  of  the 
synovial  cavity,  the  pus  removed,  the  cavity  washed  out,  and  the 
limb  put  on  a  splint.  Quinin  enjoys  a  well-earned  reputation  to 
control  pain  and  limit  extension. 

MUSCULAR  RHEUMATISM. 

Muscular  rheumatism  occurs  in  children  of  from  five  to  fifteen 
years  of  age.  It  often  follows  exposure  to  wet  or  drafts,  and 
especially  when  to  these  is  added  fatigue.  Indiscretions  in  diet 
followed  by  constipation  may  in  older  children  be  a  not  infrequent 
cause.  The  exciting  causes  are  :  constipation,  improper  clothing, 
especially  shoes  that  are  too  thin,  any  underclothes  or  socks 


RHEUMATIC    FEVER.  363 

other  than  wool,  warm  and  damp  weather,  imprudences  in  diet, 
depressing  conditions  generally,  overfatigue,  and  loss  of  sleep. 
The  parts  of  the  body  most  usually  attacked  are  the  shoulders, 
neck,  and  back,  and  the  pain  is  pronounced  on  movement. 
There  is  little  constitutional  disturbance  or  heart  involvement. 
Muscular  rheumatism  is  likely  to  be  confounded  with  neuralgia, 
and  may  take  the  form  of  head  pain.  The  urine  is  generally 
highly  colored  and  loaded  with  urates.  The  best  treatment  is 
prevention,  cold  baths,  and  care  of  the  skin  generally,  along  with 
suitable  clothes.  In  acute  attacks  Dover's  powder  acts  most 
promptly,  or  atropin  hypodermically,  followed  by  saline  diuretics. 
Extreme  dry  or  wet  heat,  iodin,  methyl  salicylate,  galvanism, 
also  rubefacients,  are  efficacious.  Nothing  will  drive  away  the 
stiffness  so  quickly  as  a  dry  rub  with  a  coarse  towel  or  warm 
sweet  oil,  with  or  without  a  counterirritant  like  turpentine  or 
chloroform  liniment,  the  rubbing  to  be  continued  fifteen  to  twenty 
minutes  and  followed  by  the  application  of  dry  heat,  as  hot  as 
can  be  borne.  The  most  convenient  agent  is  the  kitchen  flat- 
iron  well  heated  and  applied  over  a  thin  flannel  garment,  slowly 
moved  about  the  affected  and  adjoining  areas.  A  hot-water  bag 
is  useful  but  far  less  efficacious.  The  most  satisfactory  treat- 
ment of  chronic  muscular  rheumatism  is  a  strict  regimen,  con- 
sisting of  proper  woolen  clothing,  active  exercise  in  the  open  air, 
such  as  bicycle  riding,  tennis,  etc.,  until  the  patient  is  in  a  glow, 
or,  better,  a  sweat,  and  before  any  chill  can  have  taken  place  go 
at  once  to  a  dry  room  in  which  the  temperature  is  not  below  65° 
F.  (18.3°  C.),  and  with  the  extremities  still  protected,  rub  the 
chest,  back,  and  limbs  until  the  skin  is  dry. 

CHRONIC  RHEUMATISM. 

Chronic  rheumatism  is  very  rare  in  children,  but  recurring 
short  attacks  of  a  rheumatic  nature,  with  stiffness  and  pain,  are 
met  with.  This  requires  persistent  hygienic  measures,  along 
with  massage,  the  application  or  rubbing  in  of  ointments,  such  as 
ten  grains  of  iodin,  twenty  of  extract  of  belladonna,  to  the  ounce 
of  lanolin.  Cod-liver  oil  is  almost  a  specific. 

RHEUMATIC  PHLEBITIS. 

Rheumatic  phlebitis  is  rare  in  children.  According  to  Schmitt 
and  Virchow,  the  initial  lesion  is  found  in  the  endothelial  lining 
of  the  veins,  and  the  inflammation  spreads  gradually  until  it 
reaches  the  outer  layers  of  their  walls.  Periphlebitis  is  rare  in 


364  CONSTITUTIONAL    DISEASES. 

rheumatic  cases.  The  ultimate  cause  of  the  phlebitis  is  prob- 
ably due  to  the  presence  of  a  parasite  in  the  blood,  but  we  are  as 
yet  unable  to  prove  this  theory.  The  most  prominent  symptoms 
of  rheumatic  phlebitis  are  a  sudden  rise  of  temperature,  pain,  and 
the  presence  of  a  thickened  cord  on  palpation.  The  pain  is  due 
to  acute  degeneration  of  the  nerves  supplying  the  lining  of  the 
vein.  To  feel  the  indurated  vein,  careful  palpation  is  necessary 
sometimes,  as  the  vein  may  be  situated  deeply.  Edema  is  a  later 
symptom,  and  its  intensity  is  in  proportion  to  the  size  of  the 
infected  vessel.  If  the  edema  persists  for  some  time,  there  may 
be  complications  in  the  form  of  ecchymoses,  vesicles,  and  even 
gangrene  of  the  skin.  The  edema  is  due  to  the  action  of  the 
toxins  produced  by  the  bacterium  which  is  responsible  for  the 
thrombosis. 

Rheumatic  phlebitis  may  occur  during  an  attack  of  articular 
inflammation,  or  during  convalescence  from  such  an  attack.  It 
is  most  frequently  found  in  the  lower  extremities,  and  in  such 
cases  is  almost  always  curable.  In  other  cases  it  occurs  in  the 
upper  extremity,  and  is  almost  always  fatal.  The  occurrence  of 
pulmonary  emboli  can  be  prevented  by  immobolizing  the  limb  on 
a  wooden  trough  well  padded  with  cotton  and  placed  on  several 
pillows  to  favor  return  circulation.  The  pain  may  be  relieved  by 
means  of  anodyne  liniments.  Against  the  edema,  which  appears 
later,  the  best  measure  is  compression  of  the  limb  by  means  of 
a  bandage,  which  must  be  applied  over  a  layer  of  cotton.  The 
atrophy  which  follows  in  these  cases  may  be  treated  by  baths, 
which  should  be  luke-warm  at  first,  then  hot,  and  followed  by  a 
short  treatment  with  massage  ;  salt  baths  and  a  sojourn  at  one  of 
the  seaside  resorts  are  of  value  in  convalescence. 


RACHITIS. 

Rachitis,  or  rickets,  is  a  disorder  of  nutrition  primarily,  but  so 
numerous  and  characteristic  are  the  attending  disturbances  of  the 
nervous  system  that  it  may  be  regarded  as  secondarily  a  neuro- 
sis. Rachitis  is  a  complex  constitutional  disorder  of  childhood, 
occurring  between  the  ages  of  six  months  and  two  years,  char- 
acterized chiefly  by  evidences  of  defective  nutrition  affecting  all 
the  structures,  but  more  conspicuously  the  bones,  and  a  lack  of 
tone  in  the  ligaments,  causing  bow-legs,  knock-knees,  flat-foot, 
and  weakness  of  the  muscles.  It  is  distinctly  a  preventable 
disease. 

Along  with  these  phenomena  are  frequently  seen  profound  ner- 
vous symptoms,  craniotabes,  with  its  resulting  hyperemia,  and 


RACHITIS.  365 

other  cerebral  disorders,  insomnia  due  to  this,  night-terrors, 
irritability  of  temper,  at  times  rising  into  maniacal  attacks ; 
laryngismus  stridulus,  convulsions,  hydrocephalus,  tetany,  with 
Trousseau's  symptom,  spasmus  nutans  (nodding  or  rotary 
spasm),  nystagmus,  and  hyperhidrosis.  These  states  all  may  be 
entirely  recovered  from,  and  usually  with  no  resultant  cerebral 
damage.  Digestion  is  also  seriously  deteriorated  ;  there  is  a 
marked  tendency  to  intestinal  and  other  catarrhs,  anemias,  and 
vitiation  of  the  blood. 

Rachitis  is  a  far  more  common  condition  than  statistics  would 
lead  us  to  believe.  It  often  disappears  spontaneously  under  favor- 
able circumstances  or  changed  conditions  from  those  which  pro- 
duced it.  It  is  at  the  foundation  of  much  of  the  impaired  resis- 
tance in  infancy  and  early  childhood.  When  the  active  process 
ceases  and  only  the  deformities  remain,  the  individuals  are  often- 
times most  vigorous,  both  physically  and  intellectually. 

Causes. — Rachitis  is  found  the  world  over,  chiefly  in  cities  or 
in  crowded,  underfed  communities  lacking  light  and  air,  and  is 
rare  in  country-places  or  where  the  food-supply  and  hygienic 
conditions  are  favorable.  It  is  more  common  in  Europe  than  in 
America,  and  our  supply  of  cases  of  the  disease  is  derived  mainly 
from  there.  It  is  shown  by  Morse  and  others  to  be  on  the 
increase  in  this  country.  Observers  in  the  large  clinics  of  Europe 
admit  its  appearance  in  over  30  per  cent,  of  children  applying 
for  advice.  In  this  country  it  is  not  quite  so  common  or  severe, 
even  in  our  largest  cities,  and  is  comparatively  rare  out  of 
crowded  centers  unless  brought  thence.  With  us  in  America  it 
is  seen  either  in  the  children  of  emigrants  or  in  the  negro  and 
mixed  races,  often  in  babies  who  have  been  hand-fed  or  who 
early  get  coarse  or  unsuitable  food,  particularly  when  this  is  defi- 
cient in  fat.  Snow  has  called  attention  to  the  fact  that  here  it  is 
most  noticeable  in  the  transplanting  of  a  southern  race  to  a 
northern  climate.  It  appears  now  and  again  in  the  families  of 
the  well-to-do,  even  among  the  rich,  especially  where  nervous 
mothers  coddle  their  children  overmuch  or  practice  erroneous 
methods  of  feeding  and  nursery  hygiene,  above  all  if  enough 
air  and  sunlight  are  denied  them.  Rickets  is  rarely  congenital. 
The  disease  usually  develops  between  the  first  and  second  years, 
but  may  develop  in  utero. 

Predisposition  has  much  to  do  with  the  production  of  rickets. 
The  offspring  of  parents  in  feeble  health,  overworked  and  under- 
fed, with  poor  digestion  and  assimilation,  a  senile  father  or  a 
mother  from  any  cause  exhausted,  as  by  prolonged  lactation, 
discharges  of  pus  or  blood,  etc.,  is  apt  to  be  rachitic.  Rachitis 


366  CONSTITUTIONAL    DISEASES. 

is  not  distinctly  hereditary,  although  at  times  it  has  the  appear- 
ance of  being  so. 

Parental  syphilis,  alcoholism,  and  tuberculosis  frequently  in- 
duce rachitis.  Infants  who  begin  life  with  an  unfavorable  inheri- 
tance, and  who  are  confined  in  dark,  filthy,  overcrowded  houses, 
especially  in  damp  cellars,  are  very  prone  to  develop  the  disease  ; 
even  those  who  begin  with  good  constitutions  may  thus  become 
rachitic.  The  most  powerful  factor  is  food  deficient  in  certain 
essential  qualities,  as  fat  and  albuminoids.  Breast-fed  infants 
usually  escape,  but  not  always,  and  those  who  depend  upon 
breast  milk  from  poorly  nourished  mothers  or  upon  the  parental 
supply  for  too  long  a  time  are  liable  to  the  disease.  Even 
where  the  supply  of  food  is  good  and  yet  the  digestion  is  too 
weak  to  cope  with  it,  infants  may  thus  be  affected.  Those 
infants  who  have  been  fed  on  the  proprietary  foods  are  especially 
prone  to  this  disorder.  If  the  strength  be  reduced  by  any  cause, 
such  as  summer  diarrheas,  rachitis  may  begin  without  any 
intervening  stage  (Eustace  Smith).  Rickets  is  a  frequent  sequel 
of  exhausting  infantile  disorders,  especially  in  one  predisposed. 

General  Symptoms  of  Rachitis. — The  first  symptoms  of 
rickets  in  a  child  are  fretfulness,  disturbed,  intermittent  sleep, 
and  slight  fever  at  night.  The  little  patient  becomes  mildly 
cross,  repelling  advances,  its  pillow  becomes  wet  with  sweat 
during  sleep,  beads  of  perspiration  appearing  first  on  the  fore- 
head and  face.  It  seems  to  suffer  from  a  sensation  of  heat  or 
oppression,  and  kicks  and  throws  off  the  bedclothes,  inducing  a 
peril  from  chilling  of  the  areas  thus  exposed,  especially  as  the 
surface  is  usually  abnormally  damp  and  the  skin  relaxed.  There 
is  always  marked  pallor,  and  often  a  diffuse  soreness  and  tender- 
ness of  the  body.  The  indisposition  on  the  part  of  the  little 
sufferer  to  be  moved,  however,  is  not  due  to  the  tenderness  of 
the  joints,  unless  scurvy  be  present,  but  rather  on  account  of  the 
respiratory  distress  induced.  The  digestion  is  markedly  dis- 
turbed by  flatulence,  fetid  stools,  and  diarrhea,  with  evidences 
of  intestinal  catarrh.  The  appetite  is  often  ravenous,  espe- 
cially for  meat  and  fatty  substances.  The  digestion  is  slow, 
however,  and  imperfect,  and  food  is  passed  undigested,  the  stools 
having  a  most  abominable  odor,  often  curdy-looking  and  sur- 
rounded with  mucus.  The  liver  and  spleen  are  often  enlarged, 
and  dentition  is  delayed.  The  spleen  is  palpable,  or  definitely 
enlarged  in  over  half  the  cases,  or,  according  to  Starck,  in  68  per 
cent.  The  enlargement  of  the  spleen  corresponds  with  the  de- 
gree of  anemia  present.  This  condition  is  not  a  part  of  the 
process,  but  probably  due  to  toxins  produced  by  the  rachitic 


RACHITIS.  367 

condition.  The  veins  about  the  head  are  seen  to  be  large  and 
full.  On  being  touched,  the  child  shrinks  away  or  cries  ;  the 
flesh  is  sore,  but  this  is  probably  due  to  a  morbid  state  of 
the  periosteum  or  cartilaginous  junctures,  though  not  entirely, 
because  the  abdomen  is  also  tender.  The  child  is  comfortable 
only  when  lying  quietly  or  held  carefully  in  the  arms.  In 
some  there  is  a  slight  temperature-rise  in  the  latter  part  of  the 
day,  and  a  moderate  quickening  of  the  pulse.  After  a  time 
changes  in  the  skeleton  occur,  first  to  be  felt  and  later  to  be 
seen.  Craniotabes,  or  thinning  of  the  occipital  bones  in  spots, 
is  a  very  characteristic  deformity,  occurring  during  the  first  year, 
usually  before  the  tenth  month.  This  is  a  source  of  consid- 
erable peril,  because  of  leaving  areas  of  the  brain  undefended 
by  proper  mechanical  protection.  The  condition  is  often  as- 
cribed to  a  double  infection  of  syphilis  and  rickets  acting  to- 
gether. Such  a  child  is  more  than  ordinarily  fretful,  especially 
when  lying  down,  because  in  this  position  pressure  is  exerted 
almost  directly  on  exposed  areas  of  the  brain.  Cerebral  circula- 
tion is  thus  disturbed,  hence  sleep  is  unquiet,  the  child  awakens 
readily,  and  needs  to  have  its  position  altered.  This  possibility 
of  varying  pressure  may  produce  considerable  disturbance  of  the 
vasomotor  and  cardiac  centers  in  the  medulla.  Many  slight 
changes  are  thus  produced  in  the  brain,  oftentimes  but  tempo- 
rary, exaggerating  the  well-known  susceptibility  of  rachitic  infants 
to  neuroses.  Laryngismus  stridulus,  or  glottic  spasm,  while  not 
common,  is  a  characteristic  phenomenon,  occurring  suddenly 
with  an  arrest  of  respiration,  seemingly  a  palsy  of  the  respira- 
tory center  ;  the  face  becomes  deadly  pale,  a  moderate  rigidity 
of  the  limbs  sets  in,  with  carpopedal  spasms.  After  a  few 
seconds  a  long,  deep,  effortful  inspiration  is  made,  and  this, 
passing  through  the  narrowed  chink  of  the  glottis,  causes  a 
whistling  sound  or  cock  crow,  and  the  attack  ends  with  a  waking- 
up  of  the  patient  in  a  dazed  and  surprised  condition.  Rachitic 
infants  are  especially  liable  to  convulsions,  also  to  tetany.  These 
unfortunate  children  are  peculiarly  defective  in  their  power  of 
resistance.  The  altered  shape  of  the  chest-wall,  which  is  often 
a  lateral  depression  of  the  ribs  and  thrusting-out  of  the  sternum 
anteriorly,  produces  changes  in  the  shape  of  the  organs  within. 
The  heart  is  not  seriously  affected,  but  the  completeness  of  its 
movements  is  interfered  with.  The  lungs,  moreover,  can  not 
expand  properly,  from  which  may  come  a  host  of  symptoms  due 
to  impaired  circulatory  and  respiratoiy  completeness,  of  little 
importance  in  moderate  health,  but  acting  as  a  source  of  great 
danger  in  disease.  A  partial  collapse  of  certain  lobules  of  the 


.368  CONSTITUTIONAL    DISEASES. 

lung  is  likely  to  occur  on  slight  congestion,  especially  along 
their  thin  edges.  The  lateral  and  posterior  parts  suffer  from 
pressure,  and  the  anterior  borders  may  become  emphysematous. 
If  in  such  an  one  bronchitis  or  bronchopneumonia  occurs,  the 
elimination  of  mucopus  is  difficult  and  cyanosis  of  a  serious  sort 
readily  arises.  When  coughing  occurs  in  a  rachitic  child, — and 
it  is  a  frequent  symptom, — it  continues  in  spite  of  relatively  little 
local  irritation  and  is  difficult  to  allay.  A  peculiar  form  of 
"  pressure  palsy  "  is  sometimes  seen  in  rachitic  children,  owing 
to  inflammatory  change  in  the  vertebrae  compressing  the  cord, 
and  from  this  they  almost  always  recover.* 

The  acute  form  of  rachitis  is  recognized  by  a  marked  febrile 
movement  and  greater  tenderness  than  occurs  in  the  usual  slow 
variety  and  in  which  the  joint  swellings  appear  more  quickly. 

The  change  in  the  bones  of  the  head  leaves  the  fontanel  open 
long  after  it  should  have  closed  (at  about  eighteen  months),  and 
at  a  year  and  a  half  to  two  years  it  may  be  one  to  two  inches 
wide.  The  head  is  usually  larger  than  that  of  a  normal  child, 
and  by  contrast  to  the  shrunken  body  seems  much  larger.  The 
urine  usually  contains  calcareous  salts  or  phosphates. 

Deformities. — A  child  distinctly  rachitic  is  a  conspicuous  and 
familiar  object  in  all  clinics,  and  in  the  practice  of  all  except  phy- 
sicians in  very  fortunate  rural  localities.  Those  in  whom  the  dis- 
order is  less  graphically  marked  can  yet  be  readily  recognized 
by  a  well-defined  train  of  phenomena. 

The  general  appearance  of  a  rachitic  child  is  that  of  one  badly 
modeled  by  a  novice.  Pallor  is  a  constant  feature  ;  the  blood  is 
low  in  hemoglobin,  below  50  per  cent,  or  less,  sometimes  there 
is  a  leukocytosis,  but  the  red  cells  are  little,  if  at  all,  affected. 
Most  rachitic  babes  are  soft  and  doughy,  lacking  in  tone,  with 
little  resistance  in  any  of  the  fat  tissues.  As  they  grow  older 
the  lymph -nodes  become  enlarged  and  the  tonsils  hypertrophy, 
as  do  also  the  adenoid  tissues  about  the  vault  of  the  pharynx. 

The  mucous  membranes  are  easily  disturbed,  both  in  the 
respiratory  organs  and  in  the  intestines  and  bowels.  Diges- 
tion is  poor,  and  diarrhea  easily  induced  and  difficult  to  check. 
Fortunately,  the  appetite  is  usually  good,  especially  for  fats 
and  flesh  meats,  so  much  needed  ;  these  articles  are  readily 
assimilated.. 

Catarrhal  attacks  are  liable  to  run  a  protracted  course  and  ex- 


*  One  of  us  reported  three  instances  of  rachitic  pseudopalsy  occurring  in  a  well- 
to-do  family  where  twenty  cases  in  all  had  been  noted. — "Annals  of  Gyn.  and 
Fed.,"  December,  1891. 


RACHITIS.  369 

tend  broadly.  The  nervous  disturbances  have  been  alluded  to. 
They  are  dependent  upon  defective  nutrition  of  the  centers,  which 
in  children  are  in  an  undifferentiated  state,  and  interference  in 
their  proper  growth  is  quickly  followed  by  profound  perturbation 
of  function. 

Dentition  is  apt  to  be  very  late,  slight  congestive  stages  of 
tooth  growth  and  eruption  are  enough,  in  a  rachitic  child,  to 
act  as  exciting  causes  to  the  very  unstable  condition  of  its  ner- 
vous forces  ;  hence  these  children  suffer  extremely  from  what  is 
usually  a  normal  process. 

The  order  of  teething  is  not  changed  materially,  though  it  may 
be  very  irregular,  nor  are  the  teeth  themselves  defective  ;  this 
last  in  sharp  contrast  to  syphilis,  which  is  said  by  some  to  be  so 
closely  connected  with  rachitis. 

The  more  graphic  phenomena  of  rachitic  children  are  the 
deformities,  essentially  symmetric,  first  seen  in  the  enlargement 
of  the  bony  junctures,  especially  the  ribs  and  the  costal  carti- 
lages, forming  the  much-quoted  "  rosary."  This  latter  is  present 
in  nearly  all  cases  and  is  a  valuable  diagnostic  sign. 

An  osseous  thickening  is  marked  in  the  center  of  the  parietal 
bones  and  the  bases  of  the  temporal  bones.  The  development 
of  the  bones  of  the  jaw  is  arrested,  especially  the  upper  jaw  and 
malar  bones,  hence  the  disproportionate  smallness  of  the  face  is 
both  apparent  and  real. 

The  head  appears  to  be  too  large  and  is  out  of  proportion  to 
the  body,  though  not,  as  a  rule,  of  much  greater  circumference 
than  a  normal  head.  It  is  usually  square,  because  of  the  promi- 
nence of  the  parietal  bones,  and  flattened  at  the  vertex  and  occi- 
put. Sometimes  this  is  accompanied  by  a  sulcus,  or  furrow,  in 
the  midline,  anteroposteriorly,  and  laterally  along  the  coronal 
suture.  The  sutures  remain  open  much  longer  than  in  healthy 
heads.  The  fontanel  is  open  as  late  as  the  end  of  the  third  year 
in  some  instances. 

The  chest  is  frequently  deformed  by  the  bending-in  of  the  ribs 
at  the  costocartilaginous  junctures,  lateral  depressions  over  the 
lower  third  of  the  thorax  and  eversion  of  the  lower  borders  of 
the  ribs  are  present.  The  ensiform  cartilage  is  sometimes  mark- 
edly depressed,  leaving  a  circular  concavity.  The  cause  for  this 
is  largely  atmospheric  pressure  from  without  not  being  counter- 
balanced by  internal  resistance  upon  the  malleable  ribs. 

This  deformity  of  the  chest  interferes  seriously  with  the  sym- 
metric development  of  the  thoracic  and  other  organs.    The  aorta 
has   been   reported  deformed   (Jacobi),  being  bent  upon  itself, 
impeding  the  heart  action  and  circulation.      It  is  because  of  this 
24 


3/O  CONSTITUTIONAL    DISEASES. 

impeded  circulation  that  rachitic  children  are  subject  to  attacks 
of  dyspnea  and  bronchitis. 

The  spleen  and  liver  are  commonly  enlarged  and  crowded 
downward,  because  of  the  narrowing  of  the  thorax.  The  kid- 
neys, too,  are  often  displaced,  especially  in  cases  showing  much 
scoliosis  and  rendering  them  more  liable  to  nephritis. 

The  spine  is  not  generally  deformed,  but  kyphosis,  or  posterior 
protrusion,  is  the  most  common  ;  occasionally  there  is  rotation. 
The  pelvis  rarely  escapes  some  distortion,  generally  a  diminution 
of  the  anteroposterior  diameters.  The  limbs  undergo  conspicu- 
ous changes  in  shape  from  the  malleable  state  of  the  bones,  and 
slight  muscular  strains  increase  these  as  activity  progresses. 

Enlargement  of  the  epiphyses  is  the  characteristic  feature, 
commonest  at  the  wrist,  sometimes  at  the  elbow.  The  long 
bones  suffer  deformity,  particularly  of  the  legs,  from  the  pres- 
sure on  them  while  attempts  are  made  at  standing.  This  induces 
bow-legs  and  knock-knees,  rarely  a  curve  in  the  femur.  While 
sitting,  however,  a  more  marked  double  curve  is  given  to  the 
lower  limbs  from  the  cross-legged  attitude  long  continued.  In 
the  early  stages  of  deformity,  while  the  bones  are  so  soft  that 
they  can  be  bent  by  the  hand,  braces  are  of  most  value.  These 
must  reach  above  the  knee,  and  should  be  provided  with  rods 
placed  opposite  the  points  of  greatest  convexity,  and  exert  con- 
tinuous pressure.  Success  varies  with  the  individual  case.  If 
the  bones  can  not  be  remodeled  thus,  osteotomy  is  demanded, 
and  the  orthopedic  surgeon  should  be  consulted  early  in  the 
case,  not  only  to  operate  or  brace,  but  critically  to  watch  prog- 
ress and  correct  deformities  early. 

After  the  third  or  fourth  year  braces  usually  do  little  good  with- 
out some  form  of  cutting  operation  on  the  bone  itself.  Many 
children  are  too  poor  to  pay  for  braces,  which,  to  be  efficient, 
must  be  well  made  and  kept  in  perfect  repair,  and  plaster-of- 
Paris  bandages  may  then  be  used  with  advantage.  The  different 
bones  of  the  same  individual  vary  in  density :  the  leg  of  one 
side  and  the  thigh  of  the  other  may  be  soft,  while  the  corre- 
sponding bones  on  the  other  side  may  be  hard  ;  but  this,  of  course, 
is  not  the  rule. 

For  a  description  of  the  braces  most  commonly  used  the 
reader  is  referred  to  the  works  on  orthopedic  surgery,  as  well  as 
for  the  details  as  to  the  operation  of  osteotomy.  The  latter  con- 
sists in  cutting  through  the  femur  and  straightening  the  thigh  for 
knock-knees,  or  through  the  tibia  and  fibula  for  bow-legs.  It 
may  be  necessary  to  operate  upon  both  the  femur,  tibia,  and 
fibula  at  the  same  time  before  the  leg  is  straightened.  The  bone 


RACHITIS.  371 

may  be  simply  cut  through  and  the  leg  straightened,  or,  if  the 
deformity  be  very  great,  a  wedge-shaped  piece  may  be  cut  out 
of  the  convexity  of  the  bone  to  insure  a  good  result. 

The  limb  should  then  be  enveloped  in  cotton,  or  a  plaster-of- 
Paris  bandage  applied  to  keep  the  limb  straight. 

In  young  children,  especially,  it  is  sometimes  well  to  suspend 
the  limbs  from  a  frame  at  right  angles  to  the  axis  of  the  body  ; 
this  insures  extension,  and  at  the  same  time  keeps  the  bandage 
free  from  being  soiled  with  the  urine  and  feces.  The  limb  should 
be  kept  longer  in  plaster  than  for  the  healing  of  an  ordinary 
fracture,  as  the  repair  of  bone  is  somewhat  delayed,  owing  to  the 
rachitic  condition. 

Pathology. — While  true  that  the  most  conspicuous  changes 
are  observed  in  the  ends  of  the  long  bones  and  ribs,  the  morbid 
anatomy  is  that  of  a  constitutional  disease,  a  blood  dyscrasia, 
affecting  the  nutrition  of  nearly  all  tissues  of  the  body,  thereby 
producing  disease  in  the  osseous  system  which  is  closely 
allied  to  inflammation.  The  primary  lesion  is  hyperemia  of  the 
periosteum,  the  marrow,  the  cartilage,  and  of  the  bone  itself. 
The  disturbance  of  the  normal  growing  bone  causes  changes  in 
the  bone  already  formed.  The  cartilage  cells  of  the  epiphyses 
consequently  undergo  increased  proliferation  from  four  to  eight 
times  more  than  they  do  in  a  normal  growing  bone.  The  matrix 
is  softer  ;  as  a  result,  the  bone  which  is  formed  from  this  abnormal 
cartilage  lacks  firmness  and  rigidity.  The  increased  proliferations 
of  cells  makes  the  epiphyses  larger,  swollen  in  appearance,  ir- 
regular in  outline,  and  very  much  softer  in  consistence.  The 
high  vascularity  favors  the  process  of  absorption  in  the  bones 
already  formed,  so  that  the  relation  between  removal  and  deposi- 
tion of  lime  salts  is  disturbed,  absorptions  having  taken  place 
more  rapidly.  It  has  been  experimentally  proved  that  hyperemia 
of  bone  causes  defective  deposition  of  lime  salts.  In  the  parieto- 
occipital  region  and  in  some  other  cranial  areas  ossification  is 
retarded,  so  that  the  bone  readily  yields  to  pressure  by  the  finger 
(craniotabes).  The  fontanels  are  not  promptly  closed,  by  reason 
of  delayed  ossification.  The  frontal  and  parietal  protuberances 
are  very  much  enlarged,  due  to  exaggerated  proliferation  of  the 
periosteum,  so  that  the  head  acquires  a  broad  forehead,  with 
characteristic  frontal  eminence,  a  condition  mistaken  for  hydro- 
cephalus.  When  ossification  begins  to  take  place  the  bones 
become  large,  heavy,  and  irregular  in  outline.  These  changes 
correspond  to  the  graphic  clinical  manifestations — bow-legs, 
knock-knees,  pigeon-breast,  spinal  curvature,  and  square  cra- 
nium. The  wrists,  ankles,  knees,  and  ribs  at  points  at  the  junction 


3/2  CONSTITUTIONAL    DISEASES. 

of  the  bone  and  cartilages  become  enlarged  ;  on  the  ribs  they 
occur  in  a  series  simulating  beads,  which  is  called  the  "  rachitic 
rosary."  The  prominent  visceral  change  is  the  enlargement  of 
the  spleen  and  liver.  The  splenic  enlargement  is  not  a  primaiy 
but  a  secondary  process,  probably  due,  as  has  been  said,  to  toxic 
disturbance  the  result  of  some  essential  process.  At  first  the 
enlargement  is  due  to  an  increase  in  the  pulp,  later  in  the  con- 
nective tissue.  Starck  found  the  spteen  enlarged  in  over  one- 
half  of  the  autopsies  on  rachitic  children  and  in  68  per  cent,  of 
living  cases. 

Prognosis. — The  disease  is  not  fatal  of  itself,  but  death  often 
readily  results  in  the  enfeebled  organism  from  some  intercurrent 
malady.  Under  proper  treatment  recovery  takes  place,  with  some 
resulting  deformity. 

Treatment. — As  has  been  said,  we  may  assume  that  nearly 
one -third  of  all  the  children  of  our  city  population,  and  perhaps 
a  fourth  of  others,  exhibit  the  evidence  of  rickets  or  may  readily 
acquire  the  disorder.  Therefore,  a  thorough  consideration  of 
detailed  treatment  can  not  be  out  of  place.  We  will  review  here 
an  outline  of  such  systematized  measures  as  are  suitable,  and  in 
the  chapter  on  General  Considerations  on  Physical  Development 
the  matter  will  be  treated  more  fully.  The  first  consideration  is 
prevention  ;  here  it  is  necessary  to  face  the  question  of  accepting 
or  rejecting  degenerate  immigrants — a  matter  which  is  probably 
about  to  play  a  very  important  part  in  politics. 

The  next  step  is  to  give  our  attention  to  pregnant  women  who 
are  of  these  devitalized  classes  and  races.  If  this  can  be  done, 
much  may  be  accomplished.  Bathing,  good  air,  sunlight,  and 
abundant,  well-cooked  food  will  accomplish  much.  A  short 
residence  in  the  country  would  do  more.  The  relief  of  the 
coming  mother  from  exhausting  labor  and  overwrought  emotion 
is  also  of  great  value.  The  result  of  such  care  may  be  a  pretty 
fair  child,  and  upon  such  a  little  one  continued  liberalizing  influ- 
ences will  work  to  great  advantage,  and  a  few  generations  of  such 
measures  regenerate  a  moderately  good  population.  The  rachitic 
baby  should  be  kept  in  a  room  which  faces  the  south,  whence 
come  the  best  breezes  in  summer  and  sunlight  at  all  times.  It 
should  be  kept  at  a  temperature  in  the  neighborhood  of  70°  F. 
(21.1°  C.),  with  the  windows  much  open,  or  on  sheltered  house- 
tops or  piazzas,  wearing  extra  clothing  the  while.  Underwear 
should  be  of  wool,  thin  in  summer  and  thicker  in  winter  ;  bathing 
should  be  daily,  as  much  for  tonic  action  as  for  cleanliness.  If 
the  extremities  become  chilly  after  this,  or  at  any  time,  it  is  easy 
and  valuable  to  apply  external  heat.  The  breast  milk  of  the 


RACHITIS.  373 

mother  is  always  the  best,  and  during  lactation  she  should  take 
tonics  and  extra  food  rich  in  fats  and  albuminoids.  The  mothers 
of  the  poorer  classes  fill  themselves  up  on  bread  and  tea  while 
nursing  a  baby ;  they  had  better  live  on  milk  and  meat.  It  is 
important  that  mothers  of  babies  showing  rickets  should  sacrifice 
something  to  the  needs  of  lactation.  Good  breast  milk  when 
insufficient  is  of  little  use  if  supplemented  by  coarse,  ill-cooked 
"table  food."  Poor  breast  milk  is  better  than  none,  because  it 
can  be  made  better  unless  the  mother  be  distinctly  infected,  as 
by  tuberculosis.  The  natural  supply  can  be  supplemented  by 
suitable  food  better  than  to  depend  upon  hand-feeding  alone. 
For  rachitic  babies  this  extra  diet  is  nearly  always  necessary, 
certainly  after  eight  or  ten  months.  The  extra  food  should  be 
cow's  milk  modified  by  water,  milk,  sugar,  cream,  and  an  alkali, 
and  possibly  some  "  casein  breaker  "  or  attenuant,  such  as  barley 
or  oatmeal  water.  The  milk  formulas  should  first  have  a  low 
percentage  of  proteid  and  a  moderately  large  amount  of  fat,  and 
later,  as  the  digestion  becomes  stronger,  both  these  milk  elements 
should  be  increased.  This  should  alternate  with  strong  animal 
broths  and  but  little  or  no  starch  food.  Starch  feeding  produces 
rickets  in  those  predisposed.  Weaning  should  not  be  allowed 
in  the  hot  months,  certainly  not  in  our  large  cities.  In  the  prepa- 
ration of  milk  the  first  requisite  is  proper  care  as  soon  as  it 
leaves  the  cow,  and  this  is  receiving  most  gratifying  attention  at 
the  hands  of  dairymen. 

If  the  milk  be  sound  and  kept  so,  it  need  not  be  subjected 
to  heat  to  fit  it  for  use.  As  ordinarily  supplied  it  will  require 
Pasteurization  or  sterilization ;  the  latter,  however,  can  not  be 
used  but  for  a  short  time.  Simple  boiling  over  a  water-bath 
does  fairly  well,  especially  for  older  children.  Prepeptonization 
is  of  great  use,  particularly  for  one  or  two  meals  in  a  day,  and 
along  with  supplemental  diet. 

Properly  prepared  cereal  solutions,  as  of  barley  or  oatmeal 
water,  are  not  only  cheap  and  convenient  diluents,  but  of  real 
value  to  separate  particles  of  casein  and  prevent  lumpy  curds  in 
the  stomach,  and  they  are  in  themselves  nutritious.  They  are 
far  better  when  diastase  has  been  added.  The  amounts  and  in- 
tervals of  feeding  are  of  as  much  importance  as  quality.  Breast- 
fed infants  of  vigorous  stock  may  survive  some  insufficiency,  but 
the  feeble,  rachitic  infant  should  receive  overfeeding  rather  than 
underfeeding.  The  value  of  overfeeding  or  forced  feeding  in  chil- 
dren has  not  been  studied  enough  except  where  the  food  was  of 
bad  quality. 

It  often  happens  that  a  very  young  child,  especially  a  rachitic 


374  CONSTITUTIONAL    DISEASES. 

one,  will  greedily  devour  and  thrive  notably  on  a  liberal  diet  of 
beef  and  mutton. 

Constitutional  treatment  must  be  instituted  in  the  first  half  year 
or  year  to  be  efficient.  Little  can  be  expected  after  the  second 
year,  for  by  that  time  we  have  chiefly  the  effects  of  the  disease, 
not  the  disease  itself,  to  deal  with. 

For  the  deformed  chest,  and  its  resultant  cramped  lungs, 
regulated  gymnastics  are  indicated.  Rarefied  air  deserves  more 
extended  trials.  For  kyphosis  extension  and  postural  treatment 
are  indorsed,  along  with  prolonged  rest  in  bed. 

Medicinal  Treatment. — Rachitic  children  are  particularly 
liable  to  gastric  and  intestinal  disturbances  and  weaknesses ; 
their  stomachs  are  usually  hyperacid  and  need  alkalies  ;  for. the 
relief  of  this  in  the  infant  pancreatic  extract  with  soda  is  of  use  ; 
in  older  children  well-diluted  muriatic  acid  and  pepsin  are  better  ; 
also  there  should  be  supplied  other  secretions  of  the  intestines 
which  assist  assimilation.  Peptenzyme,  or  similar  preparations 
purporting  to  contain  the  active  ferment  from  most  of  the  intes- 
tinal glands,  has  a  useful  function.  It  may  be  well  to  mention 
here  the  malt  preparations  as  being  useful  if  there  be  no  diar- 
rhea, and  to  be  added  to  starch  food  or  given  alone.  The  great 
remedy  for  rickets  is  cod-liver  oil,  because  of  its  fat,  and  not  less 
because  of  its  bile  salts,  and  of  less  than  half  its  value  if  these 
biliary  principles  are  destroyed  or  injured  in  the  preparation.  To 
cod-liver  oil  may  be  added  with  advantage  raw  eggs,  glycerin, 
or  syrup,  and  spirits  or  some  heavy-bodied  wine  or  cordial.  If 
we  could  be  sure  of  getting  a  cod-liver  oil  made  from  fresh 
livers  of  fresh  codfish,  and  prepared  by  cold  expression,  we 
would  have  the  best  thing  obtainable.  Some  years  ago  this  was 
forthcoming  at  the  hands  of  an  old  sea  captain  named  Stone,  of 
Swampscott,  Mass.  A  favorite  preparation  of  the  authors  is  : 
Place  in  an  eight-ounce  bottle  one  raw  fresh  egg ;  glycerin, 
Y?.  of  an  ounce  ;  maraschino,  curacoa,  sherry,  or  port  wine, 
YZ  of  an  ounce;  cod-liver  oil,  six  ounces;  shake  thoroughly, 
and  keep  on  ice  in  the  dark,  and  give  a  dessertspoonful  before 
two  principal  meals.  Russell's  emulsion  of  the  mixed  fats  is 
of  great  value.  One  drug  which  enjoys  a  large  reputation 
in  overcoming  with  great  promptitude  and  thoroughness  the  de- 
fects of  bone  growth  in  rickets  is  phosphorus.  This  should  be 
given  in  small  dose — -^\^  to  y^  of  a  grain  after  meals.  Iron, 
manganese,  and  arsenic  are  of  value  for  the  anemia.  To  relieve 
sweating,  atropin,  picrotoxin,  and  the  cardiac  tonics  are  useful,  as 
well  as  aromatic  sulphuric  acid. 


SCORBUTUS.  375 


SCORBUTUS. 

Synonyms. — INFANTILE  SCURVY;  BARLOW'S  DISEASE;  PERIOSTEAL 

CACHEXIA. 

Infantile  scurvy  is  a  constitutional  disease  characterized  by  the 
symptoms  of  malnutrition,  attended  with  general  debility,  anemia, 
petechiae  and  ecchymoses  in  various  parts  of  the  body  (princi- 
pally upon  the  lower  extremities  and  mucous  membranes  of  the 
mouth),  general  muscular  weakness,  amounting  to  immobility  in 
the  lower  extremities  (going  on  to  pseudoparalysis).  The  dis- 
ease is  attended  with  swelling  about  the  joints  and  tenderness 
along  the  lines  of  the  long  bones.  It  rarely  terminates  fatally 
when  placed  under  proper  treatment,  and  it  etiologically  holds 
an  important  relation  to  the  deprivation  of  fresh  foods. 

Causes. — Infantile  scorbutus  usually  develops  insidiously  :  a 
predisposition  to  rickets,  scrofula,  and  the  existence  of  hereditary 
syphilis  must,  of  necessity,  increase  the  tendency  to  the  produc- 
tion of  the  disease.  There  can  be  no  doubt  that  in  the  various  pro- 
prietary infant  foods  and  sterilized  milk  there  is  often  lacking  a 
certain  something  which  is  needed  for  a  proper  nutrition  of  the 
tissues,  and  from  such  conditions  scurvy  often  arises.  Faulty 
assimilation  may  in  some  instances  be  sufficient  to  lay  the  foun- 
dation for  an  attack.  It  would  appear  that  the  source  of  the  evil 
is  to  be  found  in  an  impaired  power  of  assimilation  from  the 
beginning.  No  known  micro-organism  has  been  discovered  to 
produce  the  disease. 

Pathology. — Though  we  have  been  enabled  to  perform  but 
few  autopsies,  the  lesions  found  are  of  sufficient  importance  to  de- 
serve attention.  The  blood,  microscopically,  presents  the  appear- 
ance observed  in  anemia,  varying  in  degree  with  the  severity  of  the 
attack.  The  red  blood-corpuscles  have  varied  in  the  observations 
we  have  made  from  2,200,000  to  3,800,000  in  a  cubic  millimeter, 
hemoglobin,  from  80  per  cent,  to  50  per  cent.  The  red  blood- 
corpuscles  frequently  presented  the  regular  appearance  known  as 
poikilocytosis,  with  no  other  notable  change.  In  one  case  slight 
pigmentation  was  observed. 

Macroscopically,  hemorrhages,  petechial  and  ecchymotic,  are 
frequently  observed  in  the  muscles,  kidneys,  spleen,  gastro- 
intestinal tract,  and  osseous  system  (principally  subperiosteal). 
Ophthalmoscopic  examination  has  shown  hemorrhages  into  the 
retina  which  have  disappeared  under  treatment.  With  the  ex- 
ception of  the  subperiosteal  hemorrhages,  the  skin  and  the 
mucous  membranes,  principally  of  the  mouth,  are  most  fre- 


376  CONSTITUTIONAL    DISEASES. 

quently  affected.  Extensive  ulceration  of  the  gums,  with  ex- 
uberant granulation,  overlapping  the  teeth  and  obscuring  them 
entirely  from  view,  is  not  an  uncommon  condition  in  the  advanced 
stage  of  the  disease.* 

In  cases  terminating  fatally  hemorrhages,  both  microscopic 
and  macroscopic,  have  been  observed  in  all  the  organs  and  tissues 
of  the  body — the  condition  becomes  an  actual  blood  dyscrasia. 

Symptoms. — The  symptoms  of  infantile  scorbutus  are  both 
constitutional  and  local.  The  attack  may  be  precipitated  by  a 
number  of  acute  symptoms,  gastro-intestinal  in  character,  with 
fever  and  the  constitutional  disturbance  associated  therewith. 
The  temperature  ranges  from  100°  to  102°  F.  (37.8°  to  38.9°  C.)  ; 
a  fever  of  105°  F.  (40.5°  C.)  and  above  is  rare.  More  often  the 
disease  develops  insidiously.  The  child  becomes  peevish  and 
fretful,  the  appetite  capricious,  though  usually  poor,  temperature 
but  slightly  above  normal,  frequently  holding  within  the  normal 
range.  The  child  lies  upon  its  back,  with  limbs  extended  or 
slightly  flexed.  The  anemia,  which  at  first  was  slight,  becomes 
more  marked,  and  with  it  excessive  irritability.  Pressure  along 
the  tibia  and  femur  and  about  the  knee  and  ankle-joints  is 
attended  with  considerable  pain  ;  the  child  cries  out,  but  makes 
but  feeble  effort  to  be  released.  If  the  disease  is  far  advanced, 
the  position  becomes  characteristic,  the  pain  becomes  acute — 
now  the  slightest  movement  causes  the  little  patient  to  cry  out 
as  if  in  great  suffering.  The  excessive  tenderness  about  the 
extremities  has  frequently  occasioned  the  affection  to  be  mis- 
taken for  one  of  acute  rheumatism.  The  joints  themselves 
are,  however,  seldom  affected.  If  the  skin  is  carefully  exam- 
ined, not  infrequently  distinct  petechiae  with  ecchymoses  may 
be  observed  upon  the  legs  and  thighs.  Oftener  the  mucous 
membranes,  especially  the  gums,  show  evidences  of  the  disease  ; 
there  may  be  but  slight  swelling.  This  is  frequently  the  case 
before  the  eruption  of  the  first  teeth  ;  afterward  the  gums  be- 
come swollen,  red,  and  suffused  with  blood.  The  spongy  areas 
show  a  tendency  to  bleed  upon  pressure.  This  conditiori  may 
grow  worse,  going  on  to  ulceration,  and  presenting  in  places 
patches  of  localized  gangrene,  the  overlapping  of  the  gums  com- 
pletely obscuring  the  teeth  from  view.  In  a  case  which  came 
under  our  observation  which  had  been  treated  locally  with  a 
solution  of  nitrate  of  silver  there  was  presented  all  the  appearance 
of  linear  ulcers  along  both  the  upper  and  lower  gums,  with  exu- 


*  See  "Boston  Medical  and  Surgical  Journal,"  October  29,  1896,  article  on  "In- 
fantile Scorbutus,"  by  Joseph  Leidy,  M.D. 


SCORBUTUS.  377 

berant  granulations  from  which  there  was  constant  oozing  of 
blood.  The  enlargement  about  the  joints  deserves  special  note. 
The  swelling  is  along  the  shaft  of  the  long  bones,  about  the  line 
of  separation  between  the  diaphyses  and  epiphyses,  and  outside 
of  the  joint  proper.  The  parts  are  sensitive  to  pressure,  and 
become  extremely  painful  as  the  disease  advances.  There  is  no 
rise  in  the  local  temperature  of  the  part.  The  indisposition  of 
the  patient  to  move  the  limbs  is  due,  primarily,  to  the  pain  which 
is  produced  upon  motion,  and  in  advanced  stages  of  the  disease 
to  muscular  weakness.  This  symptom  has  frequently  been  mis- 
taken for  paralysis.  The  electric  reactions  of  the  muscles  are, 
however,  normal ;  the  knee-jerk  is  usually  lessened  or  lost. 
This  condition  of  pseudoparalysis  is  rarely  present  in  the  arms. 

The  heart  and  circulatory  apparatus  present  no  symptoms 
of  importance,  except  partaking  of  the  constitutional  symp- 
toms associated  with  the  febrile  movement.  In  a  number  of 
instances  hemic  murmurs  have  been  noted  where  the  anemia  has 
been  marked.  The  presence  of  moist  rales  in  the  lungs,  poste- 
riorly, is  not  unusual.  Hemoptysis  is  rare,  but  when  present, 
may  be  considered  a  grave  symptom. 

Kidneys. — Albuminuria  is  not  infrequent.  The  presence  of 
hyaline  and  blood-casts  is  not  rare,  according  to  various  author- 
ities. In  nine  cases  observed  by  us,  however,  in  but  one  were 
blood-casts  and  hyaline  tube-casts  noted. 

The  symptoms  of  infantile  scorbutus  vary  in  degree  from  attacks 
of  slight  severity  to  the  more  advanced  and  aggravated  forms.  We 
have  observed  that  the  hemorrhagic  condition  of  the  gums  is  no 
guide  to  the  state  of  the  lesions  in  other  parts  of  the  body.  For 
instance,  in  a  case  which  presented  but  slight  swelling  of  the  gums 
there  were  persistent  hematuria  and  numerous  spots  upon  the  skin. 
On  the  other  hand,  in  a  case  in  which  the  gums  were  extensively 
involved,  the  swelling  about  the  joints  was  slight,  with  no  marked 
symptoms  referable  to  the  lower  extremities.  In  another,  where 
the  patient  was  brought  to  us  as  a  supposed  case  of  rheumatism, 
the  weakness  in  the  lower  extremities  was  considerable,  the  skin 
showing  a  marked  petechial  eruption  over  the  anterior  portion 
of  both  legs,  with  no  involvement  of  the  gums  ;  and  in  still  an- 
other, the  hemorrhagic  state  was  general :  on  the  gums,  about 
the  pillars  of  the  fauces,  with  the  presence  of  blood  in  the  urine 
and  stools,  and  no  involvement  of  the  skin.  In  a  case  supposed 
to  be  one  of  infantile  palsy  there  was  simply  weakness  in  the 
lower  extremities,  extreme  sensitiveness  to  pressure  over  the  shafts 
of  the  tibia  and  femur,  with  slight  sponginess  of  the  gums, 
marked  diarrhea,  and  profound  anemia. 


3/8  CONSTITUTIONAL    DISEASES. 

Diagnosis. — From  the  insidious  nature  of  infantile  scorbutus, 
the  history  of  the  case,  and  the  character  of  the  symptoms  there 
can  be  no  difficulty  in  reaching  a  correct  diagnosis.  General 
debility,  anemia,  spongincss  and  bloody  extravasation  of  the 
gums,  petechiae  and  ecchymoses  upon  the  skin,  especially  upon 
the  lower  extremities,  enlargement  and  tenderness  about  the 
joints  and  along  the  shafts  of  the  long  bones,  and  an  apparent 
loss  of  power,  muscular  rather  than  nervous  in  origin,  in  infants 
fed  upon  one  of  the  proprietary  foods  or  sterilized  milk,  present 
a  picture  characteristic  of  scurvy  ;  finally,  the  therapeutic  test 
referred  to  under  treatment. 

Until  within  recent  years  infantile  scorbutus  was  considered  a 
rare  affection,  doubtless  due  to  the  old  classification,  which  in- 
cluded the  disease  under  the  head  of  rickets,  purpura  in  its 
various  forms,  and  hereditary  syphilis. 

Differential  Diagnosis. — Infantile  scorbutus  is  most  fre- 
quently confounded  in  the  early  stages  with  acute  rheumatism. 
The  records  of  cases  show  this  to  be  a  most  common  source  of 
error.  The  absence  of  marked  febrile  disturbance  and  the  loca- 
tion of  the  swelling  about  the  joints,  the  condition  being  devoid 
of  local  inflammation,  aid  us  in  distinguishing  the  true  nature  of 
the  attack.  In  rheumatism  the  swelling  is  confined  to  the  syno- 
vial  sac  ;  in  scurvy  it  is  above  and  outside  of  the  joint  proper. 
From  rickets  scorbutus  is  to  be  differentiated  by  the  history  of 
the  attack  and  absence  of  the  evidences  of  rickets,  the  rapid  sub- 
sidence of  the  symptoms  under  treatment,  all  of  which  go  to 
exclude  the  diagnosis  of  an  affection  the  symptoms  of  which  are 
usually  of  prenatal  origin.  In  those  cases  where  scurvy  occurs 
in  children  previously  the  subject  of  rickets  the  diagnosis  might 
appear  difficult  ;  but  even  here  the  rapid  disappearance  of  the 
acute  symptoms  under  treatment  would  aid  us  in  eliminating  a 
distinctly  constitutional  disease. 

Prognosis. — Except  in  the  advanced  stage  of  the  disease, 
associated  with  marked  constitutional  disturbance,  the  prognosis 
is  good.  Fortunately,  it  is  a  disease  which  rapidly  responds  to 
treatment.  In  those  cases  seen  late,  and  which  have  been  neg- 
lected, the  vitality  being  low,  the  hopes  for  recovery  are  not  en- 
couraging, though  even  here  it  is  astonishing  what  can  be  done 
by  a  properly  arranged  regimen. 

Duration. — The  duration  of  the  disease  is  variable.  In 
cases  early  placed  under  treatment  improvement  may  be  rapid, 
the  acute  symptoms  rapidly  subsiding.  Instances  where  the 
disease  extends  over  a  longer  period — from  six  months  to  a 
year — are  not  rare  ;  the  danger  of  laying  the  foundation  for 


SIMPLE    ATROPHY.  379 

organic  disease  must  not  be  lost  sight  of.  Relapses  are  not 
uncommon. 

Treatment. — The  etiology  of  this  affection  is  a  sufficient 
guide  to  the  treatment.  First,  change  of  food  to  a  diet  rich  in 
fresh  foods  is  all  essential,  and  is  a  sine  qua  non  of  a  character 
suitable  to  the  age  of  the  child.  Orange-juice,  beef-juice,  with 
the  use  of  perfectly  fresh  clean  milk,  for  infants,  have  proved 
ample  in  our  hands.  Medicinally,  the  use  of  minute  doses  of 
citrate  of  iron  and,  later,  arsenic  in  the  form  of  Fowler's  solution 
become  useful  adjuncts.  Hot  and  cold  douches  to  the  extremi- 
ties, in  conjunction  with  rapid  friction,  prove  highly  beneficial 
during  convalescence  when  the  progress  is  slow. 

In  those  cases  which  show  evidences  of  gastro-intestinal  irrita- 
tion the  use  of  predigested  milk  is  most  satisfactory.  The  suc- 
cess which  follows  upon  the  above  course  of  treatment  has 
occasioned  the  term  "  therapeutic  test  "  being  applied  to  it.  We 
can  not  too  strongly  urge  the  course  of  a  mixed  diet,  rich  in 
fresh  food,  nor  can  we  too  strongly  condemn  the  use  of  steril- 
ized milk  as  a  routine  diet  for  infants.  In  the  Pasteurization  of 
milk  we  obtain  the  same  results  without  the  destruction  of 
those  elements  essential  to  a  proper  nutrition  of  the  animal 
tissues. 

SIMPLE   ATROPHY. 

Synonyms. — INFANTILE  ATROPHY  ;  MARASMUS;  ATHREPSIA  ;  SIMPLE 

WASTING. 

A  pathologic  condition  characterized  by  extreme  wasting,  com- 
mon enough  as  the  result  of  many  forms  of  disease  in  infants 
and  young  children,  especially  the  subacute  or  chronic  gastro- 
intestinal diseases.  The  majority  of  cases  of  so-called  marasmus 
are  nothing  more  than  continued  starvation,  produced  by  the 
lack  of  nutritive  elements  in  the  food,  supplemented  by  a  chronic 
toxemia  from  milk  bacteria,  producing  first  a  continued  gastro- 
enteric  catarrh,  and  later  the  group  of  symptoms  of  which  wast- 
ing is  the  most  prominent  symptom.  It  is  doubtful  whether  in- 
fantile atrophy  ought  ever  to  be  described  as  a  separate  disease, 
— it  is  rather  a  group  of  symptoms, — and  yet  many  authors  of 
wide  experience,  notably  Eustace  Smith,  Holt,  and  Starr,  have 
so  described  it.  Holt  defines  infantile  atrophy,  or  marasmus,  as 
"the  extreme  form  of  malnutrition  seen  in  infancy,  occurring, 
so  far  as  is  known,  without  constitutional  or  local  organic 
disease.  It  is  a  vice  of  nutrition  only."  It  must  be  clearly 
borne  in  mind  that  the  immediate  cause  of  true  simple  atrophy 


380  CONSTITUTIONAL    DISEASES. 

lies  more  in  the  weak  assimilative  powers,  inherited  or  ac- 
quired, of  the  infant  itself,  than  in  any  fault  of  its  food,  although 
the  latter  may  be  a  potent  predisposing  factor.  All  diseases  in 
which  wasting  is  a  symptom,  such  as  tuberculosis,  infantile  syph- 
ilis, and  diseases  of  the  stomach  and  intestines,  must  not  be 
included  in  this  class. 

Causes. — Marasmus  is  seen  much  more  frequently  among  the 
poor — the  class  who  come  to  hospitals  and  dispensaries — than 
among  the  well-to-do.  It  is  a  disease  of  the  city  slums,  where 
children  are  crowded  in  tenements  amid  the  worst  hygienic  sur- 
roundings. When  seen  among  the  better  classes  it  is  usually  in 
infants  born  prematurely  or  in  children  of  parents  who  for  gen- 
erations have  been  under  the  average  of  health  or  the  victims  of 


FIG.  35. — ACUTE  ATROPHY  (ACUTE   MARASMUS). — (From  patient  in  the  Department  of 
Obstetrics  and  Diseases  of  Infancy,  Poly  clinic  Hospital,  Philadelphia.} 

inherited  disease.  It  occurs  in  premature  infants  not  infrequently, 
and  especially  in  premature  children  of  very  young,  badly  nour- 
ished mothers.  By  far  the  largest  number  of  cases  which  come 
under  our  notice  have  been  fed  on  badly  prepared  milk,  usually 
milk  and  water,  none  too  clean,  the  proprietary  foods,  and  con- 
densed milk.  "  Table  food  "  given  too  soon  may  be  a  cause. 
Occasionally,  but  rarely,  we  have  seen  a  milder  form  of  maras- 
mus in  infants  whose  mother's  milk  was  shown,  by  analysis,  to 
contain  all  the  elements  in  proper  proportion,  but  in  all  of  these 
cases  the  children  themselves  were  below  the  average  in  weight 
and  general  health,  and  in  some  of  them  evidences  of  prenatal 
rickets  later  appeared. 


SIMPLE    ATROPHY.  381 

Pathology. — Autopsies  made  on  children  dying  of  marasmus 
are  generally  unsatisfactory  in  their  results,  so  far  as  finding  any 
changes  pathognomonic  of  the  condition.  Holt  states  that  in 
one-third  of  his  autopsies  he  found  fatty  degeneration  of  the 
liver  :  the  organ  was  enlarged  and  considerably  above  the  normal 
weight. 

The  brain  is  usually  anemic,  with  dark  fluid  in 'the  sinuses; 
marantic  thrombi  are  rare.  Frequently  small  areas  of  hypbstatic 
pneumonia  will  be  found  in  the  lungs  ;  these  are  most  common  on 
the  posterior  borders  of  both  lungs,  involving  the  pulmonary  tis- 
sue to  a  depth  of  half  an  inch.  Areas  of  atelectasis  may  be  seen 
in  the  lower  lobes  of  the  lungs  of  young  infants  ;  the  pleurae  are 
normal.  The  heart,  spleen,  and  kidneys  are  anemic,  but  other- 
wise normal.  Dilatation  of  the  stomach  is  sometimes  present. 
The  intestines  contain  food  and  sometimes  mucus.  Some  enlarge- 
ment of  the  solitary  follicles  of  the  colon  and  small  intestine 
may  occur,  Peyer's  patches  may  be  increased  in  size,  and  en- 
largement of  the  mesenteric  glands  may  also  be  seen. 

Holt  summarizes  the  pathology  of  the  disease  as  a  failure  of 
assimilation  from  imperfect  digestion,  due  to  improper  food  and 
unhygienic  surroundings  or  feeble  constitution,  and  from  this 
results  a  progressive  loss  of  weight,  feeble  circulation,  imperfect 
expansion  of  the  lungs,  and,  in  consequence  of  this,  deficient 
oxidation  of  the  blood  takes  place.  The  temperature  is  lowered, 
and  finally  a  deterioration  occurs  in  the  blood  itself.  At  last  a 
point  is  reached  where  the  small  amount  of  resistance  ends  and 
the  child  dies. 

Symptoms. — At  birth  such  children  may  be  fairly  well  nour- 
ished and  may  so  continue  until  for  some  cause  weaning  is  neces- 
sary, and  the  infant  is  fed  on  some  infant  food  or  badly  prepared 
milk.  From  this  time  the  child  begins  to  lose  weight,  and 
although  it  may  be  fed  frequently,  it  seems  to  have  a  constant 
desire  for  food.  Almost  from  the  first  the  infant  is  irritable,  cry- 
ing continually  and  never  seeming  satisfied.  Soon  the  loss  of 
weight  begins  to  show  :  the  form  loses  its  plumpness,  the  out- 
lines of  the  ribs  are  seen,  and  the  various  joints  are  plainly 
marked.  The  wasting  is  most  distinct  in  the  limbs  and  face,  the 
latter  assuming  an  expression  which  is  eminently  characteristic 
of  the  disease.  The  eyes  become  sunken,  and  the  great  wasting 
in  the  lower  part  of  the  face  makes  the  forehead,  by  contrast, 
appear  unusually  prominent.  The  whole  face  assumes  a  triangu- 
lar shape,  the  ears  are  prominent,  the  cheeks  are  sunken,  while 
deep  furrows  appear  around  the  mouth.  The  expression  is  curi- 
ously aged.  The  child  soon  becomes  anemic,  with  considerable 


382  CONSTITUTIONAL    DISEASES. 

reduction  in  hemoglobin.  Holt  states  that  in  his  cases  he  has 
seen  the  hemoglobin  as  low  as  30  per  cent.,  and  in  one  case  it 
was  reduced  to  18  per  cent.  There  is  extreme  pallor,  especially 
of  the  face,  except  late  in  the  disease,  when  patches  of  pulmonary 
atelectasis  occur,  giving  the  skin,  from  nonaeration  of  the  blood, 
a  somewhat  leaden  hue.  Heart  murmurs,  due  to  anemia,  are 
frequent.  The  abdomen  is  generally  distended  and  filled  with 
gases,  produced  by  faulty  digestion.  The  muscles  appear  to  be 
small  and  atrophic,  and  are  covered  by  no  fat.  The  skin  hangs 
in  folds,  and  is  generally  dry  and  scurfy.  Various  forms  of  skin 
eruptions  are  common  ;  the  buttocks  and  genitals  are  covered  by 
erythema.  Thrush  or  other  forms  of  stomatitis  are  frequent ; 
bed-sores  appear  later.  The  temperature  may  be  normal,  sub- 
normal, or  slightly  elevated.  Most  commonly  it  is  below  the 
norm;  it  may  fall  as  low  as  95°  or  96°  F.  (35°  to  35.6°  C.). 
Not  infrequently  there  is  a  slight  rise  at  night.  The  appetite, 
which  is  generally  ravenous  in  the  early  part  of  the  disease,  fails 
entirely,  and  when  food  is  taken,  it  is  followed  by  severe  vomiting. 
The  tongue  is  coated,  the  digestion  poor,  and  the  power  of 
assimilation  in  most  cases  is  practically  nil.  The  bowels  are  con- 
stipated or  irregular  ;  there  may  be  diarrhea.  The  movements 
are  greenish  yellow  in  color  and  contain  considerable  mucus. 
Colic  is  nearly  always  present.  The  nervous  symptoms  are 
sometimes  very  severe ;  in  the  earlier  stages  the  child  is  restless, 
particularly  at  night ;  the  whole  nervous  system  is  hypersensitive, 
this  showing  itself  in  a  strong  tendency 'to  convulsions.  In  the 
late  stages  there  may  be  some  retraction  of  the  head  and  a 
decubitus  much  like  that  seen  in  tubercular  meningitis.  Physical 
signs  referable  to  the  heart  and  lungs  are  generally  negative,  ex- 
cept that  there  may  be  anemic  murmurs,  before  referred  to, 
and  a  certain  amount  of  bronchial  irritation  is  very  commonly 
seen.  Small  areas  of  pulmonary  atelectasis  may  be  found,  or  the 
evidences  of  hypostatic  pneumonia  ;  these  latter  usually  appear 
toward  the  end,  and  are  a  grave  symptom.  The  urine  is  of  a  dark- 
yellowish  color,  and  ranges  from  lOlO  to  1013  in  specific  gravity. 
Albumin  and,  more  rarely,  sugar  may  be  found  in  it.  Edema 
may  be  a  symptom,  and  when  it  appears,  is  nearly  always  a  sign 
of  a  fatal  termination. 

Diagnosis. — The  disease  with  which  simple  atrophy  is  most 
likely  to  be  confounded  is  general  tuberculosis ;  indeed,  the 
symptoms  of  the  two  diseases  are  so  much  alike  that  it  is  impos- 
sible sometimes  to  differentiate  between  them  without  an  autopsy. 
Cases  of  tuberculosis  are  sometimes  seen  with  few  symptoms 
except  those  of  marasmus,  and  occasionally  children  dying  of 


SIMPLE    ATROPHY.  383 

simple  atrophy  will  have  a  few  patches  of  tubercle  in  their  lungs. 
Even  when  pulmonary  dullness  is  present, — and  it  often  is  late 
in  the  disease, — it  may  be  from  hypostatic  pneumonia.  Holt, 
however,  has  pointed  out  that  the  dullness  of  hypostatic  conges- 
tion is  most  likely  to  be  found  in  the  posterior  portions  of  the 
lungs,  while  that  of  tuberculosis  is  commonly  in  the  anterior 
lobes.  In  some  cases  the  infant  affected  with  marasmus  may  be 
healthy  at  birth,  the  disease  developing  later,  while  tuberculosis 
may  develop  at  a  very  early  age.  In  tuberculosis  the  elevation 
of  temperature  is  greater  and  more  regular,  with  morning  remis- 
sion and  evening  rise.  Frequently  the  pulmonary  symptoms  are 
rather  more  marked  than  are  those  of  acute  atrophy.  Tubercu- 
lar meningitis  may  be  differentiated  by  the  presence  of  general 
meningeal  symptoms,  the  palsies,  or  contraction,  the  long-con- 
tinued decubitus,  and  the  full  pulsating  fontanel,  the  latter  in 
simple  atrophy  being  depressed.  The  scaphoid  abdomen  is  usu- 
ally seen  in  meningitis,  while  in  atrophy  it  is  enlarged  or  entirely 
depressed.  In  meningitis  there  is  usually  the  hydrocephalic  cry. 
Syphilis  may  be  distinguished  by  its  characteristic  eruption,  the 
presence  of  mucous  patches,  and  the  specific  coryza  seen  soon 
after  birth.  Enlargement  of  the  liver,  spleen,  and  knee-joints 
will  aid  in  the  diagnosis. 

Prognosis. — The  outlook  for  recovery  depends  considerably 
on  the  age  of  the  child,  the  younger  the  patient,  the  worse  the 
prognosis.  The  duration  of  the  disease  is  also  a  factor  to  be 
taken  into  account ;  naturally,  a  child  affected  with  marasmus 
for  a  long  time  will  be  more  reduced  in  its  powers  of  resistance 
than  one  in  whom  the  condition  has  lasted  but  a  short  time. 
The  most  important  element  in  the  prognosis  is  the  previous  care 
which  the  infant  has  received,  especially  in  the  matter  of  its  food 
and  general  hygiene.  In  those  infants  who  have  been  fed  for  a 
long  time  on  badly  prepared  artificial  foods  the  prognosis  is  not 
the  best.  In  our  experience  the  worst  cases  have  been  those 
who  have  been  fed  on  condensed  milk  since  birth.  In  these  the 
prognosis  has  generally  been  unfavorable. 

Treatment. — The  most  important  element  in  the  treatment  of 
simple  atrophy  is  its  prevention.  This  among  the  poor,  the  class 
in  which  it  is  most  common,  should  consist  in  teaching  the 
mothers  from  the  first  the  proper  manner  in  which  to  feed  their 
babies.  In  most  cases  it  is  very  little  if  any  more  trouble  for  a 
mother  to  prepare  milk  in  a  proper  and  cleanly  manner  than  in 
an  improper  and  dirty  way,  and  she  will  usually  do  the  former 
if  she  is  taught  how.  In  dispensaries  a  few  clearly  printed  rules 
can  be  used,  giving  explicit  directions  as  to  the  proper  manner  of 


384  CONSTITUTIONAL    DISEASES. 

preparing  milk  and  other  foods  employed  ;  these  directions  should 
include  the  general  care  of  the  child,  as  to  its  bathing,  clothes, 
and  exercise.  These  children  should  receive  as  much  fresh  air 
as  possible,  and  the  necessity  of  regular  bathing  should  be  im- 
pressed on  the  mother.  It  is  also  of  importance  that  infants 
with  weak  digestive  powers  should  be  fed  from  the  breast  for  at 
least  nine  months,  providing  the  mother's  milk  is  fairly  good. 
If  the  maternal  supply  has  become  so  much  decreased  that  the 
infant  can  not  be  entirely  fed  from  the  breast,  it  is  better  to  use 
mixed  feeding — rpartly  breast  and  partly  modified  cow's  milk — 
than  wholly  to  depend  on  artificial  feeding.  Wet-nurses  are  of 
great  use  in  this  class  of  patients,  and  should  be  frequently 
employed  if  the  infant  is  under  six  months  old.  Among  the 
poor  and  ignorant  the  use  of  milk  modified  at  home  will  often 
result  in  failure,  yet  by  patiently  teaching  the  mother  how  to  so 
feed  her  child  we  may  often  accomplish  much.  In  hospitals 
and  among  the  well-to-do  artificial  feeding  by  carefully  prepared 
modified  milk  will  frequently  be  successful,  particularly  if  the 
infant  is  over  six  months  old.  At  first  a  milk  mixture  low  in 
proteids  and  fats  should  be  used,  and  this  will  frequently  have 
to  be  predigested.  A  formula  such  as  the  following  may  be 
found  useful : 

Fat, I        to  5  per  cent. 

Sugar, 6        to  7         " 

Proteids, 0.75  to  I          " 

In  one  case  we  were  successful  with  the  following  : 

Fat, , 3    per  cent. 

Sugar, 6         " 

Proteids,       0.4      " 

If  these  are  assimilated,  the  proportion  of  fat  and  proteids 
must  be  raised  from  time  to  time.  The  child  should  be  weighed 
at  regular  frequent  intervals.  In  very  young  infants  with  sub- 
normal temperature  incubation  is  often  of  use,  or,  a  couveuse 
not  being  at  hand,  the  child  may  be  wrapped  in  raw  cotton  and 
laid  in  a  basket  or  small  crib,  with  one  or  two  bottles  of  hot 
water  or  a  hot-water  bag.  The  management  in  these  cases  is 
very  much  the  same  as  that  of  premature  infants.  Holt  suggests 
that  they  be  made  to  cry  vigorously  several  times  a  day,  in  order 
to  keep  the  lungs  expanded.  In  older  children  massage  with  oil 
inunctions  is  of  use.  Drugs,  as  a  rule,  are  of  very  little  account. 
If  the  child  improves,  a  change  of  air  at  the  seaside  or  mountains 
may  prove  of  benefit. 


DIABETES    MELLITUS.  385 

DIABETES   MELLITUS. 

Diabetes  mellitus,  also  called  saccharine  diabetes  or  glycosuria, 
is  a  constitutional  disorder  of  the  elaborative  functions  of  nutri- 
tion, characterized  by  a  persistent  and  excessive  secretion  of 
saccharine  urine,  polyuria,  great  thirst,  excessive  appetite,  rapid 
emaciation,  and  especially  in  children  an  early  fatal  termination. 

Causes. — Heredity,  and  especially  an  inherited  lessened  ca- 
pacity for  the  digestion  of  the  carbohydrates,  seems  to  play  a 
large  role  in  its  etiology.  The  disease  is  apt  to  be  a  legacy  from 
a  neurotic  or  gouty  ancestry.  Long-continued  dietetic  errors, 
by  deranging  the  processes  of  nutrition,  may  predispose  to  it. 
Exposure  to  cold,  traumatism,  acute  infectious  diseases,  climate, 
syphilis,  and  malaria,  disorders  of  the  liver  and  pancreas,  all  seem 
to  assume  an  etiologic  relation.  Its  frequency  among  Jews  is 
remarked  by  all  writers. 

Morbid  Anatomy. — No  constant  lesion  is  present  in  diabetes  ; 
those  encountered  are  usually  consequences,  rather  than  causes, 
of  the  disease.  The  pancreas  has  been  found  to  be  the  seat  of 
disease  in  a  large  proportion  of  cases,  the  conditions  observed 
being  atrophy,  fatty  degeneration,  suppuration,  and  fibrous  in- 
flammation, concretions,  cysts,  and  tumors  of  this  organ.  Com- 
plete extirpation  of  the  pancreas  in  animals  always  produces 
diabetes,  while  partial  removal  or  ligation  of  the  duct  is  not  fol- 
lowed by  such  a  result  (von  Mehring  and  Minkowski).  These 
experiments  suggest  that  it  is  the  function  of  the  pancreas  to 
control  metamorphosis  of  sugar  in  the  body.  It  has  been  sug- 
gested (Lepine)  that  the  pancreas  produces  a  ferment  which  is 
necessary  to  the  normal  metamorphosis  of  sugar.  The  liver  is 
often  enlarged  and  fatty  ;  cirrhosis  and  pigmentary  degeneration 
have  been  observed.  The  lungs  often  present  evidences  of 
tuberculosis.  The  kidneys  in  many  instances  are  diseased. 

The  infrequency  of  diabetes  in  childhood  is  to  be  explained  by 
the  activity  of  the  nutritive  processes  in  early  life.  No  theory, 
physiologic,  pathologic,  or  chemic,  will  explain  all  cases  of  dia- 
betes. It  is  known  that  it  sometimes  follows  diseases  and 
traumatisms  of  the  central  and  peripheral  nervous  systems.  Phys- 
iologic chemistry  has  demonstrated  that  glycogenesis  is  some- 
times the  result  of  interruption  in  the  metabolism  of  the  car- 
bohydrates ;  sometimes  an  inexplicable  derangement  in  the  me- 
tabolism of  the  nitrogenous  elements  of  food.  The  relation 
of  diabetes  to  the  glycogenic  function  of  the  liver  is  still  unde- 
cided ;  some  maintain  that  it  arises  from  the  arrest  of  the  carbo- 
hydrates in  the  liver,  or  from  the  arrested  or  perverted  glycogenic 
25 


386  CONSTITUTIONAL    DISEASES. 

function  of  the  liver,  so  that  sugar  is  poured  into  the  circulation 
and  causes  diabetes.  Others  maintain  (Pavy)  that  the  liver  is  a 
sugar-destroying  and  not  a  sugar-forming  organ,  and  claim  that 
the  carbohydrates  are  partly  converted  into  fat  in  the  intestines 
and  partly  into  glycogen  in  the  liver,  and  that  diabetes  results 
from  the  overloading  of  the  circulation  with  sugar  through  a 
failure  of  these  functions.  From  a  chemic  point  of  view  it  is 
essentially  a  disease  of  suboxidation  of  the  elements  of  food — 
nitrogenous  as  well  as  nonnitrogenous. 

Symptoms. — The  disease  in  children  differs  from  its  course 
in  adults  chiefly  in  its  more  rapid,  often  sudden,  development,  and 
in  its  early  fatal  termination.  The  child,  in  spite  of  excellent 
appetite  and  ample  food,  grows  thin  and  emaciates  rapidly,  and 
the  skin  becomes  dry  and  toneless.  Thirst  and  appetite  are  ex- 
cessive. There  is  a  frequent  desire  to  void  urine,  which  is  passed 
in  large  quantities  and  upon  examination  is  found  to  be  usually 
of  high  specific  gravity,  marked  acidity,  pale  and  sometimes 
greenish  in  color,  sweetish  taste,  aromatic  odor,  and  to  contain 
sugar  and  to  ferment  rapidly.  The  amount  of  urine  may  vaiy 
from  1000  to  6000  c.c.  (i  to  6  qts.)  in  twenty-four  hours,  the 
specific  gravity  being  from  1030  to  1040,  the  proportion  of  sugar 
from  I  to  10  per  cent.  Incontinence  of  urine  is  often  the  first 
symptom  ;  and  when  accompanied  with  thirst  and  marked  wast- 
ing, is  always  suspicious.  Peevishness,  restlessness,  itching  of 
the  genitalia,  constipation,  and  sensitiveness  to  cold  are  other 
symptoms  frequently  observed.  The  tongue  is  beefy,  red,  and 
may  be  fissured,  the  skin  dry  and  roughened,  and  the  patellar 
reflexes  are  diminished  and  at  times  lost. 

Diagnosis. — A  recognition  of  the  persistent  presence  of  sugar 
in  the  urine  determines  the  diagnosis.  A  careful  examination  of 
the  urine  should  be  made  in  all  cases  of  polyuria  or  incontinence. 
Whenever  possible,  it  is  desirable  to  examine  a  portion  of  the 
entire  quantity  of  urine  passed  in  twenty-four  hours — where  this 
is  not  obtainable,  a  specimen  voided  two  to  four  hours  after  a 
meal  is  most  likely  to  show  the  presence  of  sugar  when  the 
amount  is  small. 

Fehling's  Test. — For  qualitative  testing  take  one  cubic  centi- 
meter of  the  test  solution  and  dilute  it  with  four  cubic  centi- 
meters of  water  ;  boil  this,  and  if  no  precipitate  occurs  and  the 
solution  remains  clear,  it  is  fit  to  be  used  ;  if  not,  a  fresh  solution 
should  be  obtained.  To  the  test  solution,  after  boiling,  add  the 
urine,  drop  by  drop,  until  a  bulk  not  exceeding  the  amount  of 
test  solution  has  been  added  ;  if  no  yellow  or  red  precipitate 
takes  place,  sugar  is  absent. 


DIABETES    MELLITUS.  387 

An  approximately  accurate  quantitative  test  can  be  made  with 
Fehling's  solution,  employed  as  in  the  foregoing  test,  if  it  is  re- 
membered that  an  equal  amount  of  urine  which  exactly  reduces 
the  test  solution  contains  y2  of  I  per  cent,  of  sugar.  If  the  color 
is  removed  by  an  amount  of  urine  equal  to  half  of  the  bulk  of 
the  test  solution,  that  urine  contains  I  per  cent,  of  sugar  ;  if  the 
amount  of  urine  necessary  to  remove  the  color  from  the  test 
solution  amounts  to  twice  the  bulk  of  the  test  solution,  it  con- 
tains y^  of  i  per  cent.  Urine  containing  a  large  percentage  of 
sugar  should  be  diluted  in  the  proportion  of  I  to  9  of  water, 
and  the  diluted  urine  employed  in  testing  for  sugar ;  the  result 
obtained  should  be  multiplied  by  ten. 

Phenyl  Hydrazin  Test. — To  fifty  cubic  centimeters  of  urine  add 
from  one  to  two  grams  of  hydrochlorate  of  phenyl  hydrazin  and 
two  grams  of  sodium  acetate  ;  heat  on  a  water-bath  one  hour ; 
on  cooling  there  will  appear  at  the  bottom  of  the  beaker  a  crys- 
talline or  amorphous  precipitate,  which  under  the  microscope 
has  the  form  of  the  characteristic  yellow  needles  of  phenyl  glu- 
cosazone.  It  is  claimed  that  this  test  will  show  0.05  per  cent, 
of  sugar.  It  gives  no  reaction  with  the  other  organic  substances 
in  the  urine,  as  uric  acid,  kreatinin,  hippuric  acid,  etc. 

The  Fermentation  Test. — This  serves  the  double  purpose  of  a 
quantitative  and  a  qualitative  test.  Fill  a  four-ounce  bottle  with 
the  urine  whose  specific  gravity  has  been  determined.  To  it  add 
a  piece  of  compressed  yeast,  the  size  of  a  bean,  or  a  teaspoonful 
of  brewer's  yeast ;  mix  thoroughly,  and  stand  in  a  warm  place 
(70°  to  80°  F. — 21.1°  to  26.7°  C.)  for  twelve  hours  or  longer. 
At  the  expiration  of  this  time  the  sugar  will  have  been  converted 
by  fermentation  into  carbonic  acid  gas  and  alcohol  and  the  specific 
gravity  lowered.  For  every  degree  lost  in  specific  gravity  there 
is  one  grain  of  sugar  to  the  fluidounce.  Thus,  if  the  original 
specific  gravity  is  1040,  and  after  fermentation  1020,  there  are 
twenty  grains  of  sugar  to  the  fluidounce.  From  this  the  percent- 
age may  be  ascertained  by  multiplying  the  number  of  degrees 
lost  by  0.23.  Thus,  in  urine  losing  twenty  points  in  specific 
gravity  the  percentage  of  sugar  would  be  4.6  per  cent. 

Prognosis. — Diabetes  in  children  is  essentially  an  incurable 
disease  ;  the  younger  the  patient,  the  more  rapid  the  fatality. 
The  course  of  the  disease  rarely  exceeds  six  months. 

Treatment. — In  children  diabetes  does  not  permit  of  classi- 
fication as  it  does  in  adults,  in  whom  we  recognize  at  least  two 
forms  of  the  disease.  No  recoveries  from  true  diabetes  in  chil- 
dren have  been  reported.  The  hygienic  treatment  is  important, 
especially  the  maintenance  of  the  best  condition  of  the  skin. 


388  CONSTITUTIONAL    DISEASES. 

To  enable  one  whose  skin  is  not  robust  to  endure  and  benefit  by 
cool  bathing  it  is  an  important  safeguard  to  precede  this  by  a 
brisk  rub-down.  Patients  should  be  protected  by  woolen  clothing 
from  cold,  which  is  their  worst  enemy.  Frequent  bathing  should 
be  employed,  and  should  be  preceded  as  well  as  succeeded 
by  brisk  friction  to  keep  skin  and  circulation  active.  Guard 
against  chilling,  constipation,  and  excessive  acidity  of  the  urine. 
Outdoor  life  and  muscular  exercise,  always  short  of  fatigue, 
should  be  insisted  upon.  In  the  matter  of  diet  the  aim  should 
be,  at  the  exclusion  of  the  carbohydrates,  to  diminish  the  glyco- 
suria  and  polyuria.  The  attempt  at  absolute  exclusion  will  be 
found  useless  or  impossible,  as  the  chief  substitute  for  ordinary 
bread,  the  so-called  gluten  bread,  usually  contains  a  varying 
amount  of  starch.  It  is  probably  more  advantageous  to  permit 
a  small  amount  of  ordinary  bread  or  crusts  of  bread  and  bran 
bread,  the  amount  being  determined  by  its  effect  upon  sugar  ex- 
cretion, than  to  allow  a  large  amount  of  gluten  bread  with  its 
uncertain  amount  of  starch.  Cakes  made  of  almond  flour  from 
which  the  sugar  has  been  removed,  and  cakes  of  inula,  as  well  as 
preparations  made  from  various  other  flours,  as  poluboskos-and 
soy-bean  flour,  may  prove  of  temporary  benefit,  but  none  of  them 
will  still  the  craving  of  the  patient  for  "the  staff  of  life" — ordi- 
nary bread.  Saccharin,  glycerin,  and  levulose  may  be  used  as 
sweetening  agents. 

The  medicinal  treatment  does  not  present  much  encourage- 
ment. Aside  from  opium  preparations,  which  are  the  only  drugs 
capable  of  checking  the  disease  in  most  cases,  there  is  no  drug 
which  distinctly  influences  its  progress.  Codein  produces  the 
least  systemic  disturbance,  but  is  not  so  effective  as  the  extract 
of  opium,  which  of  all  preparations  is  the  best.  It  should  never 
be  given  in  sufficient  amount  to  produce  narcosis.  The  bromid 
of  arsenic  is  useful  in  mild  cases,  but  unfortunately  we  do  not 
meet  them  in  children.  Fluid  extract  of  ergot  in  full  doses  is 
sometimes  helpful.  Treatment  by  thyroid,  thymus,  and  pancre- 
atic extracts  internally  and  subcutaneously  has  not  met  with  suc- 
cess. Fluid  extract  of  jambul,  used  extensively  in  India,  has 
proved  another  disappointment.  Strychnin,  laxatives,  and  cod- 
liver  oil  are  useful  to  meet  symptoms.  Alkaline  waters  are  bene- 
ficial and  should  always  be  employed  when  there  is  an  excessive 
acidity  of  the  urine,  thus  warding  off  an  attack  of  coma.  Sali- 
cylate  of  soda  in  rheumatic  cases  has  obtained  some  reputation 
for  its  beneficial  effect  upon  diabetes. 


URIC    ACID    AND    URIC    ACID    CONDITIONS.  389 

URIC  ACID  AND  URIC  ACID  CONDITIONS. 

At  the  present  time  there  are  divergent  views  as  to  the  source 
of  uric  acid  and  the  seat  of  its  formation,  although  the  trend  of 
opinion  seems  to  be  in  favor  of  the  view  that  assigns  to  the  kid- 
neys the  office  not  only  of  secretion,  but  of  actual  elaboration, 
and  that  holds  that  uric  acid  is  derived  from  the  nuclein  of  the 
body-cells  (chiefly  the  leukocytes)  and  not  directly  from  the 
proteid  elements  of  the  food,  except  as  the  latter  promotes  a 
digestive  leukocytosis,  thereby  increasing  the  destruction  of 
nuclein.  Urea  also  may  contribute  its  share. 

Uric  acid  is  increased  by  food  rich  in  nuclein — bone-marrow, 
liver,  brains,  pancreas,  veal,  tea,  coffee,  meat  extracts,  and  aspar- 
agus— and  in  any  disease  that  impairs  respiration  or  circulation, 
in  affections  of  the  liver  and  spleen,  in  anemia,  in  most  acute  dis- 
eases, and  in  gout  following  the  paroxysm ;  also  by  certain 
drugs,  as  pilocarpin,  salicylic  acid,  antipyrin,  phosphorus,  etc. 
It  is  decreased  by  nonnitrogenous  diet,  in  advanced  stages  of 
disease  of  the  kidneys,  in  gout  during  the  paroxysm,  and  in  most 
chronic  states. 

Uric  acid  is  normally  in  the  urine  in  the  form  of  what  is  known 
as  the  mixed  urates  of  sodium,  potassium,  and  ammonium  (acid 
and  neutral  urates).  The  neutral  salts  are  freely  soluble  in  water, 
the  acid  urates  feebly  so,  while  uric  acid  itself  is  almost  insoluble. 
The  uric  acid  and  urates  are  held  in  solution  by  the  presence  in 
the  urine  of  the  normal  coloring-matters,  by  the  salts  (chiefly  the 
chlorids),  and  by  a  low  degree  of  acidity  ;  for  with  a  reduction  in 
the  proportion  of  the  salts  and  pigments  and  an  increase  in 
acidity  the  uric  acid  will  be  precipitated,  although  there  may  be 
less  than  the  normal  amount  present.  This  precipitation,  how- 
ever, is  pathologic  only  when  it  takes  place  while  the  urine  is 
still  within  the  body.  It  must  be  remembered  that  the  harmful 
effects  of  uric  acid  are  due  solely  to  the  mechanical  irritation  of 
its  crystals,  whether  they  be  precipitated  within  the  urinary  tract 
or  in  the  tissues  of  the  body,  for  uric  acid  itself  possesses  no 
poisonous  properties. 

When  crystals  of  uric  acid  are  deposited  in  the  tubules  of 
the  kidney,  there  may  be  present  the  symptoms  of  renal  irrita- 
tion— sense  of  weight  or  pain  in  the  lumbar  region,  or  pain 
referred  to  the  umbilicus  ;  occasionally  there  may  be  nausea  and 
vomiting.  In  other  cases  the  child  may  only  show  signs  of  mild 
mental  depression,  irritability  of  temper,  and  insomnia,  with  vari- 
able appetite  ;  constipation  is  also  apt  to  be  present.  Sometimes 
enuresis  may  be  the  only  symptom.  Whenever  such  a  train  of 


39O  CONSTITUTIONAL    DISEASES. 

symptoms,  without  obvious  cause,  makes  its  appearance  sud- 
denly, suspicion  should  always  point  to  a  possible  uric  acid  pre- 
cipitation and  suggest  an  examination  of  the  urine. 

When  the  tubules  of  the  kidneys  are  the  seat  of  actual  irritation 
from  the  continued  presence  of  uric  acid  crystals,  an  examination 
of  the  urine  would  show  the  presence  of  small  amounts  of  nucleo- 
albumin  and  serum  albumin,  usually  hyaline  casts  and  cylindroids, 
and,  occasionally,  a  few  granular  and  epithelial  casts,  or  even 
leukocytes  and  erythrocytes.  No  doubt  many  cases  of  granular 
kidney  have  had  their  origin  in  this  continued  irritation  from  uric 
acid  crystals  which  has  escaped  recognition.  Gravel  and  cal- 
culus are  attended  with  symptoms  identical  with  those  in  the 
adult. 

Although  few  cases  of  gout  in  children  are  reported,  it  is  likely 
that  it  is  often  not  recognized. 

Treatment. — The  treatment  is  dependent  upon  whether  the 
condition  is  one  of  excessive  formation  of  uric  acid  or  of  a  state 
of  lessened  solubility  of  the  urine. 

As  a  general  rule  meats  should  be  allowed  but  sparingly,  and 
only  when  a  proper  amount  of  exercise  is  taken.  This  exercise 
should  always  be  insisted  upon.  Milk,  white  of  egg,  cereals, 
lettuce,  celery,  and  fresh  fruits  constitute  the  best  diet.  Asparagus 
is  to  be  avoided,  as  it  contains  one  of  the  xanthin  bodies.  Fats 
and  starches  in  moderation  may  be  allowed  unless  they  give  rise 
to  digestive  disturbance.  When  an  oxaluria  exists,  spinach,  rhu- 
barb, tea,  cocoa,  coffee,  tomatoes,  strawberries,  etc.,  are  contra- 
indicated,  as  they  contain  oxalate  of  calcium.  Pastry  and  sweets 
have  been  shown  by  clinical  experience  to  do  harm. 

The  citrate  of  lithium  or  its  carbonate  as  an  effervescing  draft  is 
often  useful.  When  the  urine  is  strongly  acid,  alkalies  should  be 
employed,  such  as  the  citrate  of  potassium  or  bicarbonate  of  soda, 
in  doses  of  from  ten  to  twenty  grains  well  diluted.  An  evening 
dose  is  most  important,  for  it  is  during  sleep  in  the  long  fasting 
period  between  the  evening  and  morning  meals  that  the  urine 
attains  its  highest  degree  of  acidity. 

The  urine  must  be  examined  immediately  after  being  voided  and 
preferably  while  still  warm.  For  quantitative  analysis,  the  method 
of  Hopkins  is  preferred  by  the  authors  for  ordinary  use.  When 
such  test  is  impossible,  an  approximate  estimation  may  be  made 
in  the  following  way  :  Given  a  specimen  of  urine  in  which  uric 
acid  crystals  have  been  demonstrated  by  the  microscope  and  in 
which  there  is  a  fair  proportion  of  the  normal  coloring-matters 
and  salts,  accompanied  with  a  moderate  degree  of  acidity,  it  may 
be  inferred  that  the  precipitation  is  due  to  excessive  formation. 


CHAPTER  XII. 
DISEASES   OF   THE   HEART. 


GENERAL  CONSIDERATIONS. 

Anatomy. — Normally,  within  the  first  ten  days  after  birth  the 
circulation  may  be  said  to  lose  its  fetal  type  wholly  and  assume 
extra-uterine  characteristics.  The  changes  occur  at  slightly 
variable  periods.  They  include  the  conversion  of  the  ductus 
arteriosus  and  ductus  venosus  into  fibrous  cords  ;  the  closure  of 
the  foramen  ovale ;  changes  in  the  umbilical  veins  and  umbilical 
arteries,  the  first  forming  the  round  ligament  of  the  liver,  the 
second  the  true  anterior  ligament  of  the  bladder  and  the  superior 
vesical  arteries. 

In  the  early  weeks  of  postuterine  existence  one  may  clearly 
see  the  remnant  of  the  Eustachian  valve,  and  though  the  fora- 
men ovale  is  closed,  yet  it  is  distinctly  outlined.  Variations  in 
the  weight  of  the  heart  at  different  ages  are  shown  in  the  follow- 
ing table  of  Boyd's  : 

AGE.  GRAMS. 

At  birth, 20.6 

One  and  one-half  years, 44-5 

Three  years, 60.2 

Five  and  one-half  years, J2.& 

Ten  and  one-half  years, 122.6 

Seventeen  years,      233-7 

The  relative  weight  of  the  organ  is  greatest  at  birth,  and  the 
right  side  predominates  to  a  slight  degree  over  the  left.  In 
infancy  and  early  childhood  the  long  axis  of  the  heart  is  more 
horizontal  in  the  thoracic  cavity  than  it  is  in  later  life.* 

Physiology. — Independent  of  its  nervous  mechanisms  the 
cardiac  muscle  appears  to  possess  a  property  of  rhythmic  con- 
tractility. The  controlling  influence  of  the  nervous  system  is  of 
extreme  importance,  however,  in  the  lower  animals.  Ganglia 

*  Relatively,  the  heart  is  small  and  the  blood-vessels  very  large  in  capacity.  Thus, 
high  arterial  pressure  is  much  less  likely  to  result  than  in  the  adult. 

391 


392  DISEASES    OF    THE    HEART. 

and  plexuses  are  found  in  the  heart,  the  former  being  inhibitory 
or  augmentory  in  function.  The  center  for  the  extrinsic  con- 
trolling mechanism  lies  in  the  bulb,  inhibitory  impulses  passing 
from  it  down  the  pneumogastric  nerves,  and  the  majority  of  the 
augmenter  impulses  passing  down  the  spinal  cord  and  to  the 
cardiac  plexuses  through  the  medium  of  the  sympathetic  system. 

Inhibition  is  undoubtedly  nature's  method  of  conserving  tissue 
and  energy  (anabolism),  and  the  inhibitory  centers  are  constantly 
active.  Augmentation  is  synonymous  with  catabolism. 

Though  our  knowledge  of  these  central  agencies  is  far  from 
perfect,  yet  they  cast  many  important  side-lights  upon  the  func- 
tional cardiac  disturbances  in  children,  and  it  seems  clear  that 
rational  treatment  must  depend  somewhat  upon  this  physiologic 
knowledge.  The  average  pulse-rate  at  birth  is  136,  and  is  usually 
somewhat  faster  in  the  female  infant.  For  later  periods  of  life 
Holt  gives  the  following  figures  : 

Six  to  twelve  months,      105  to  115  a  minute. 

Two  to  six  years, goto  105       " 

Seven  to  ten  years, 80  to    90       " 

Eleven  to  fourteen  years 75  to    85        " 

Very  wide  variations  from  these  average  rates  'may  result, 
however,  from  most  trivial  causes.  (See  Functional  Disturb- 
ances of  the  Heart,  p.  398.) 

Examination  of  the  Heart. — The  heart  lies  so  superficially 
in  the  young  subject,  so  rapid  is  the  action,  and  so  frequent  are 
the  variations  in  rhythm  that  a  satisfactory  examination  may  be 
extremely  difficult.  A  careful  pursuance  of  the  various  steps  of 
inspection,  palpation,  percussion,  and  auscultation  is  always  more 
or  less  fruitful  of  results. 

The  ribs  in  a  child  are  placed  more  horizontally  than  in  the 
adult ;  the  diaphragm  is  higher,  therefore  the  heart  is  higher  in 
the  thorax.  The  heart  is  also  more  horizontal,  with  the  apical 
impulse,  especially  in  the  very  young,  felt  somewhat  outside  of 
the  mammillary  line. 

The  liver  in  young  children  is  larger  in  proportion  than  in 
adults,  hence,  as  the  heart  is  in  close  contact  with  this,  the 
area  of  cardiac  dullness  merges  into  that  of  the  liver  dullness 
below.  Though  the  heart  does  float  in  the  pericardial  fluid,  it 
changes  very  little  in  the  different  positions  assumed  by  the  child. 
Bulging  of  the  precordia  in  the  child  may  constitute  a  most  im- 
portant evidence  of  cardiac  disease. 

We  can  scarcely  avoid  mention  of  an  old  mode  of  examina- 
tion to  which  Benedict  has  redirected  attention  recently.  We 
refer  to  a  combination  of  the  last  two  methods,  or  auscultatory 


GENERAL    CONSIDERATIONS.  393 

percussion.  This  method  has  been  frequently  applied  in  outlin- 
ing the  gastric  viscus,  but  not  until  lately  have  we  been  enabled 
to  demonstrate  its  value  in  mapping  out  the  size  of  the  human 
heart.  Only  the  deep  or  "relative"  cardiac  dullness  can  be 
studied  thus,  but  this  is  the  area  which  tells  us  most  surely  of 
the  cardiac  bulk  and  sizes  of  various  cavities.  The  lightest  im- 
mediate percussion  will  serve  in  this  study.  The  outlines  of  the 
heart  may  be  traced  upon  the  chest  with  an  anilin  dye  or  some 
oily  preparation.  These  lines  can  then  be  transferred  to  tissue- 
paper.  In  this  way  exact  records  may  be  secured  and  kept. 

The  phonendoscope  is  of  special  value  in  auscultatory  percus- 
sion, and  in  listening  to  the  sounds  of  the  heart  through  clothing. 
It  usually  interests  rather  than  annoys  the  child  who  is  being 
examined.  We  would  not,  however,  recommend  the  student  to 
depend  ^cvholly  upon  instruments  which  amplify  sounds,  but  care- 
fully to  train  his  ear  by  studying  cardiac  sounds  with  the  in- 
tervention only  of  the  examining  towel.  Thus  can  the  quality  of 
sounds,  their  rhythm,  force,  and  intensity,  be  fairly  compared. 

Starr  prefers  to  inspect  and  auscultate  before  resorting  to  the 
more  disturbing  methods  of  physical  examination. 

The  following  aphorisms  are  drawn  from  Crandall : 

1.  The  apex  lies  higher  in  the  chest  and  further  to  the  left 
than  in  the  adult. 

2.  The  apex-beat  is  hard  to  detect  in  the  infant.     In  the  child 
palpation  shows  this  easier  than  in  the  adult. 

3.  The  area  of  dullness  is  comparatively  large.     (Rotch  indi- 
cates three  stages  in  infancy  and  childhood  during  which  differ- 
ences are  noted  in  relative  and  absolute  dullness.) 

4.  Murmurs   are  heard  over  comparatively  large  areas.     A 
study  of  differences  in  the  quality  of  the  sounds  and  points  of 
greatest  intensity  will  help  us  here. 

5.  The  rate  may  be  increased  and  the  rhythm  altered  by  slight 
causes. 

6.  In  rachitic  children  and  in  those  affected  by  empyema  or 
pleural  effusions  and  adhesions  the  apex  may  appear  in  an  abnor- 
mal position. 

7.  Prominence  of  the  precordia  is  sometimes  marked.     Nor- 
mally  the   loudest  sound  is  the  first  sound  at   the  apex  ;  the 
weakest  sound  is  the  second  sound  at  the  aortic  cartilage.     This 
accords  with  our  experience,  though  it  does   not  seem   to  be 
generally  recognized  that  the  pulmonic  second  sound  is  in  early 
life  stronger  than  the  aortic  sound. 

The  examination  should  always  be  performed  during  sleep,  or 
in  a  state  free  from  physical  or  psychic  disturbance,  and  a  child 


394 


DISEASES    OF    THE    HEART. 


should  never  be  frightened  with  a  formidable  looking  stethoscope 
or  other  instrument. 

CLASSIFICATION   OF   CARDIAC    DISEASES. 


TIME  OF  OCCURRENCE. 

NATURE  OF  THE 
AFFECTION. 

CLINICAL  DISEASE. 

Intra  -  uterine     existence 
or  very  early  infancy. 

Developmental 
or 
Inflammatory. 

Various  congenital  affections. 

'  Various  motor  or  sen- 

sory   phenomena, 

unaccompanied  by 

Functional  diseases  of  the  heart. 

sensible 

changes 

of  structure. 

Dilatation         \    Alone    or    as 

Extra-uterine     existence 

'Mechani- 

ral 

i        accompani- 
\        ment  of  in- 

(infancy  or  childhood). 

Organic   • 

V*dl. 

\        flammatory 
Hypertrophy    /        change. 

Inflam- 

f Pericarditis,  acute  or  chronic. 
-|  Endocarditis,  acute  or  chronic. 

matory. 

(  Myocarditis,  acute  or  chronic. 

(  Effusions  (noninflammatory). 

Miscellaneous. 

•<  Granulomata. 

(  Neoplasms. 

The  Importance  of  Physical  Signs  other  than  Murmurs 
in  the  Diagnosis  of  Valvular  Disease  of  the  Heart. — Text- 
books teach  that  an  endocardial  murmur  is  not  always  an  evi- 
dence of  a  valvular  lesion,  and  also  that  a  valvular  defect  may 
exist  and  still  no  murmur  be  present.  Practically,  however,  con- 
clusions are  usually  based  upon  the  presence  or  absence  of 
murmur.  There  may  be  a  valvular  disease  without  a  distinct 
murmur  being  audible,  and  therefore  other  signs  than  murmur 
must  be  used  in  determining  the  existence  of  a  valvular  lesion. 
Every  valvular  lesion  of  importance  must  result  in  hypertrophy 
and  dilatation  of  the  heart  behind  the  valve  diseased.  An  in- 
crease in  tension  of  the  pulmonary  circulation  follows  any  valvu- 
lar lesion  at  the  mitral  orifice  and,  later,  any  aortic  disease.  This 
will  show  in  increased  force  of  the  pulmonic  second  sound. 

Stenosis  of  the  orifices  of  the  left  heart  means  a  smaller  amount 
of  blood  in  the  general  arterial  circulation  ;  therefore  lessened 
arterial  pressure. 

Failure  of  the  right  heart  is  followed  by  venous  congestion — 
e.  g.,  venous  pulse,  hepatic  and  portal  congestion,  anasarca,  etc. 
The  last  condition  is  much  more  frequently  dependent  upon 
renal  disease  when  it  appears  in  the  child. 


CONGENITAL    DISEASES    OF    THE    HEART.  395 

Hypertrophy  may  be  recognized  by  the  heaving,  forcible  apex 
impulse,  though  one  may  be  misled  by  a  thin  chest-wall.  Epi- 
gastric pulsation  may  call  attention  to  enlarged  right  heart.  The 
jugular  pulse,  the  hepatic,  and  the  capillary  pulse  are  all  of 
diagnostic  value.  The  visible  pulse  of  aortic  regurgitation  is 
almost  pathognomonic. 

Palpation  is  very  important,  certainly  most  important  in  locating 
the  apex-beat.  Characteristic  thrills  may  be  perceived  by  palpa- 
tion. The  force  of  the  cardiac  impulse  and  the  sites  of  abnormal 
pulsations  are  also  learned  through  touch.  Extracardiac  causes 
for  murmur,  such  as  might  arise  in  a  heart  dislocated  by  pressure 
or  retraction,  can  usually  be  excluded  by  percussion. 

A  weak  aortic  sound  may  be  an  indication  of  obstruction.  The 
reduplicated  second  sound  may  point  to  valvular  disease  (steno- 
sis of  mitral  orifice).  A  sharply  accentuated  first  sound  at  the 
apex  is  likewise  common  in  mitral  stenosis.  The  peripheral 
tones  in  aortic  regurgitation  are  a  valuable  confirmation. 

Error  in  calling  an  inorganic  murmur  organic  is  readily  made 
unless  the  secondary  sounds  are  carefully  sought  for.  We  must 
not  undervalue  the  importance  of  endocardial  murmur,  but  bear 
in  mind  that  it  is  only  by  the  complexus  of  symptoms  that  an 
accurate  diagnosis  can  be  made.  Of  all  the  evidences  of  heart 
disease,  the  least  valuable  is  the  endocardial  murmur. 


CONGENITAL    DISEASES  OF   THE   HEART. 

To  the  embryologist  and  the  pathologist  these  lesions  are  of 
considerable  interest.  To  the  clinician  less  importance  attaches 
to  them,  because  exact  diagnoses  are  sometimes  impossible,  and 
manifestly  our  best  therapeutic  measures  are  often  utterly  useless. 
In  the  last  few  years,  however,  a  rather  exceptional  experience  has 
led  us  to  array  ourselves  with  those  who  believe  that  not  infre- 
quently an  accurate  diagnosis  is  at  least  as  possible  as  it  is  in  the 
presence  of  acquired  cardiac  lesions.* 

We  believe  that  congenital  cardiac  disease  is  much  more  com- 
mon than  it  is  usually  supposed  to  be,  and  that  as  a  cause  of 
death  in  early  infancy  it  is  frequently  unrecognized. 

Hirst,  following  Baginsky,  adopts  the  classification  below 
appended  : 

i.  Patency  of  the  Foramen  Ovale. — This  lesion  is  of  slight 
importance,  unless  accompanied  by  a  marked  defect  of  the 

*  In  the  short  period  of  a  fortnight  one  of  us  saw  three  "  blue  babies"  and  an 
older  girl  who  almost  unquestionably  had  pulmonary  stenosis. 


396  DISEASES    OF    THE    HEART. 

muscular  wall.  As  a  rule,  this  lesion  is  not  accompanied  by  a 
murmur,  and  if  it  is,  the  sound  is  likely  to  be  diastolic  in  time. 
Holt  found  small  openings  in  fully  one-fourth  of  his  autopsies  on 
infants  under  six  months  old. 

2.  Defect  of  the  Ventricular  Septum. — Absence  of  this  structure 
causes  the  cor  triloculare.  Frequently  the  auricular  septum  is 
also  absent,  and  we  have  the  cor  biloculare.  This  lesion  is  com- 
monly associated  with  pulmonary  stenosis.  When  in  the  presence 
of  congenital  cardiac  disease  one  hears  a  murmur  which  is  sys- 
tolic in  time,  whose  greatest  intensity  is  at  the  midsternum,  and 
which  is  transmitted  toward  the  left,  the  probability  is  that  there 
is  a  defect  in  the  septum  ventriculorum. 

j.  Anomalies  of  the  Auriadoventricular  Valves. — These  are 
much  more  common  on  the  right  side  of  the  heart.  Such  lesions 
may  be  inflammatory  (sclerotic  endocarditis)  or  contractions  may 
follow  at  the  sites  of  small  hematomata  (Rotch).  More  rarely 
the  valves  are  bound  together,  forming  an  annular  diaphragm, 
and  in  exceptional  cases  atresia  of  the  orifice  may  be  found. 

4..  Stenosis  and  Atresia  of  the  Pulmonary  Artery. — Stenosis  of 
this  vessel  is  the  most  common  and  the  most  important  con- 
genital affection,  for,  unless  some  sudden  strain  be  thrown  upon 
the  heart,  such  cases  may  reach  adult  life. 

The  lesion  may  be  due  to  intra-uterine  endocarditis  or  it 
may  be  developmental.  Complete  atresia  is  exceedingly  rare. 
Obviously,  the  blood  supply  to  the  lungs  would  be  materially 
restricted.  Thus,  one  is  not  surprised  to  learn  that  many  of 
these  cases  perish  from  pulmonary  tuberculosis.  Subsequent 
valvulitis  is  also  to  be  expected.  Stenosis  of  the  conus  arteriosus 
is  occasionally  observed.  A  diagnosis  of  pulmonary  stenosis  is 
based  upon  the  symptoms  and  signs  of  congenital  cardiac  dis- 
ease, and  upon  the  following  finds  :  (i)  A  systolic  murmur  heard 
best  at  the  pulmonic  cartilage,  and  not  transmitted  into  the  great 
vessels.  (2)  The  presence  of  a  decided  thrill  at  the  same  site. 
(3)  Right-sided  hypertrophy  is  sometimes  observed,  though  it  need 
not  be  present  when  there  is  a  deficient  septum  ventriculorum. 

5.  Persistence  of  the  Ductus  Arteriosus. — Absence  of  this  vessel 
has  been  observed.     The  obliterative  endarteritis  (Warren)  by 
which  this  structure  becomes  closed  may  involve  the  isthmus 
aortae.     The  murmur  present  in  patulous  ductus  arteriosus  is  sys- 
tolic in  time,  heard  best  at  the  pulmonic  cartilage,  but  differs 
from  that  of  pulmonary  stenosis  because  it  is  transmitted  along 
the  great  arterial  trunks. 

6.  Stenosis  of  the  Aorta. — Stenosis  of  the  aorta  is  much  less 
common  than  the  similar  condition  of  the  pulmonary  artery,  and 


CONGENITAL    DISEASES    OF    THE    HEART.  397 

is  inversely  of  more  serious  potentiality.  Complete  atresia  may 
exist,  and,  as  in  deformities  of  the  right  side  of  the  heart,  the 
conus  arteriosus  may  be  stenosed. 

7.  Transpositions  of  the  Arterial  Trunks. — These  cases,  which 
may  be  observed  alone  or  in  connection  with  other  visceral  trans- 
positions, rarely  live  to  term.     When  other  visceral  transpositions 
accompany  the  cardiac  one,  less  difficulty  should  be  experienced 
in  diagnosis. 

8.  Numerical  Anomalies  of  the  Valve  Segments. 

q.  Gross  Anomalies. — Acardia  ;  ectopia  cordis  ;  displacement 
upward  or  downward  ;  ill-developed  heart  ;  bifid  apex  ;  absence 
of  pericardium,  etc.  These  anomalies  may  accompany  other 
gross  developmental  malformations,  such  as  spina  bifida  or  hy- 
drocephalus. 

Symptoms. — Cyanosis  is  present  in  about  90  per  cent,  of 
cases  of  congenital  deformities  of  the  heart  (Osier)  ;  it  usually 
appears  early,  but  in  a  case  seen  by  us  at  the  Philadelphia  Hos- 
pital it  was  not  present  until  a  few  hours  before  death.  The 
blueness  may  be  quite  general,  or  may  appear  only  in  the  lips, 
nose,  eyes,  fingers,  and  toes.  Peripheral  temperature  is  lowered. 
Dyspnea  and  cough  are  common  symptoms.  Such  children  are 
always  puny  of  body  and  stunted  in  mind.  The  fingers  are 
markedly  clubbed.  The  child  fails  to  develop  generally.  (See 
chapter  on  Physical  Development.) 

Diagnosis. — The  diagnosis  of  the  exact  condition  is  impossi- 
ble in  some  cases,  yet  when  cyanosis,  cardiac  hypertrophy,  and 
murmurs  are  present,  one  can  safely  say  that  there  is  congenital 
cardiac  disease  present.  We  have  briefly  outlined  the  ausculta- 
tory  signs  of  importance  in  the  diagnosis  of  the  most  common 
lesions. 

Prognosis. — This  is  grave  in  the  majority  of  instances.  A 
patulous  foramen  ovale  is  not  incompatible  with  life,  and  16  per 
cent,  of  the  cases  of  pulmonary  stenosis  reach  the  age  of  twenty 
years  (Assum). 

Treatment. — This  is  essentially  hygienic.  "  If,"  as  Jacobi 
says,  "  they  be  so  unfortunate  as  to  grow  up,  exercise  should  be 
avoided."  Warm  clothing  and  a  mild,  equable  climate  will 
serve  to  prevent  the  internal  congestions  and  the  bronchitis, 
which  may  serve  as  fatal  disturbances  to  a  damaged  and  over- 
laden circulatory  apparatus.  Salt  baths  and  inunctions  of  the 
skin  with  oil  or  fat  are  measures  that  appear  of  some  practical 
aid  in  conserving  nutrition. 

Tonics  will  be  of  use  as  indicated,  and  digitalis  may  prove  of 
service  in  crises. 


398  DISEASES    OF   THE    HEART. 


FUNCTIONAL  DISTURBANCES  OF  THE  HEART. 

During  the  developmental  epochs  the  heart  is  especially  liable 
to  disturbances  of  rhythmic  action,  but  infants,  as  a  rule,  escape. 
Older  children  are  thus  troubled,  however,  especially  as  puberty 
approaches  and  during  and  after  that  time.  Exciting  causes, 
such  as  confinement  indoors,  a  sedentary  or  overlaborious  life, 
the  use  of  improper  food,  tea,  coffee,  or  tobacco,  readily  affect 
the  growing  tissues  of  so  delicately  poised  an  organ  ;  also  the 
effect  of  poisons  of  various  sorts,  as  in  the  acute  infectious 
fevers. 

These  affections  are  practically  neuroses,  and  are  not  accom- 
panied by  demonstrable  changes  in  structure  ;  hence,  are  thus 
designated  functional. 

Wilson  classifies  the  symptoms  in  the  following  table  : 
I.   Motor  disturbances  : 

1.  Derangements  of  rhythm. 

(a)  Arhythmia ;  (^)  tachycardia. 

2.  Momentary  syncope. 
II.  Sensory  disturbances  : 

(a)  Heart  consciousness  ;  (ft)  distress  ;   (r)  pain. 

III.   Motor  and  sensory  disturbances  combined  : 
Palpitation. 

Obviously  this  is  but  a  classification  of  symptoms  and  throws 
no  light  upon  the  existing  conditions  upon  which  these  symp- 
toms are  dependent.  Indeed,  arhythmia  may  be  noticed  in  per- 
fectly healthy  children  during  sleep,  and,  as  before  mentioned, 
the  cardiac  rate  may  be  affected  by  trivial  circumstances.  On 
the  other  hand,  some  of  these  symptoms  may  be  observed  in 
organic  heart  or  brain  disease.  We  would  recall  attention  to 
our  brief  summary  of  the  physiology  of  the  heart.  It  has  been 
found  experimentally  that  the  rate,  the  force,  and  the  rhythm 
may  be  affected  by  position,  exercise,  the  condition  of  the  cardiac 
muscle,  the  states  of  activity  of  the  intrinsic  and  extrinsic  ner- 
vous centers,  the  blood  pressure,  the  degree  of  ventricular  dis- 
tention,  acids  and  alkalies  in  the  blood,  the  temperature  of  the 
blood,  the  quality  of  the  blood,  the  condition  of  the  coronary 
circulation,  local  heat  and  cold,  drugs,  also  reflexes  from  various 
localities. 

Causes. — Anemia  will  be  found  as  the  most  frequent  cause 
of  palpitation,  etc.  ;  tea-  and  coffee -drinking  is  far  from  an  uncom- 
mon factor  of  disturbed  cardiac  rate  and  force ;  exophthalmic 
goiter  is  occasionally  observed  in  childhood  ;  so  various  disor- 


FUNCTIONAL  DISTURBANCES  OF  THE  HEART.         399 

ders  of  metabolism  with  circulatory  toxins  are  competent  causes. 
Eye-strain,  dyspepsia,  gastro-intestinal  fermentation,  and  naso- 
pharyngeal  growths  will  serve  as  examples  of  reflex  causes. 

Paroxysmal  tachycardia,  so  thoroughly  studied  by  Nothnagel, 
we  have  not  observed.  It  must  be  remembered  that  many  of 
the  reported  cases  have  displayed  organic  lesions  of  the  heart  or 
nervous  mechanism  in  addition,  and  one  should  look  carefully 
for  such  lesions  before  regarding  such  individuals  as  subjects  of 
neuroses  only. 

Sansom  reports  100  cases  of  influenza,  with  tachycardia  in  37 
cases,  irregular  heart  in  25,  and  bradycardia  in  5  cases.  Our 
experience  amply  confirms  the  influence  of  the  influenza  poison 
upon  the  circulatory  apparatus.  Increase  or  slowing  of  the  rate 
and  abnormalities  of  rhythm  frequently  persist  for  a  long  time  as 
resultants  of  this  infectious  disease.  The  irregularities  in  cardiac 
action  so  frequently  seen  accompanying  chorea,  and  which  often 
pass  away,  leaving  apparently  no  lesion,  are  in  all  probability 
instances  of  slight  endocardial  damage.  These  may  not  recur, 
but  represent  too  often  the  initial  lesion,  becoming  subsequently 
serious  and  disabling. 

Diagnosis. — Our  physiologic  knowledge  of  cardiac  structure, 
action,  and  normal  variations  should  lead  us  to  investigate  etio- 
logically,  and  not  rest  content  with  the  diagnosis  of  a  symptom. 
Our  observations  at  the  Polyclinic  Hospital  would  lead  us  to 
believe  that  Da  Costa's  classification  applies  equally  to  children, 
and  that  many  cases  may  be  grouped  under  the  heads  of  muscti- 
lar  weakness  or  nervous  weakness  of  the  heart.  Of  course,  these 
conditions  may  be  accompanied  by  general  asthenic  states.  One 
could  scarcely  leave  the  subject  of  functional  disorders  of  the 
heart  without  a  reference  to  the  so-called  functional  or  accidental 
murmurs.  As  a  rule,  these  are  not  heard  in  infancy,  though  the 
question  is  a  moot  one.  These  murmurs  in  childhood,  particu- 
larly in  older  children,  are  of  fairly  common  occurrence.  Gen- 
erally they  are  systolic  in  time.  They  are  most  frequently  heard 
in  the  neighborhood  of  the  pulmonic  cartilage,  and  probably 
next  at  the  apex.  They  are  usually  soft  in  quality,  but  may  be 
quite  harsh.  Transmission  does  not  pursue  the  laws  followed  in 
valvular  disease,  but  exceptionally  these  murmurs  are  heard  over 
considerable  areas.  Enlargement  of  the  cardiac  area  is  never 
present  to  any  marked  degree. 

We  can  not  afford  the  space  to  dwell  upon  the  various  theo- 
ries advanced  to  explain  these  interesting  murmurs  ;  suffice  it  to 
say  that  no  one  theory  satisfactorily  accounts  for  all  of  these 
sounds. 


4OO  DISEASES    OF   THE    HEART. 

Prognosis. — This  will  depend  upon  the  gravity  of  the  under- 
lying conditions.  As  a  rule,  prognosis  is  decidedly  favorable 
when  organic  cause  is  excluded. 

Treatment  must  also  depend  upon  the  cause  or  causes  of  the 
symptom.  In  most  cases  it  is  largely  hygienic.  Attention  to 
diet  is  always  called  for,  as  reflexes  arising  through  the  pneumo- 
gastric  nerve — for  instance,  those  from  a  dilated  stomach — may 
mechanically  influence  the  heart.  If  syncopal  seizures  are  no- 
ticed, the  child  must  be  kept  in  bed,  and  there  treated  by  mas- 
sage, proper  bathing,  and  a  concentrated  nutritious  diet.  Iron 
and  arsenic  used  judiciously  are  of  value  in  anemia.  When  the 
first  sound  of  the  heart  is  weak,  or  when  tachycardia  is  accom- 
panied by  syncope,  strychnin  in  small  divided  doses  is  our  best 
remedy. 

Hygienic  measures  are  of  most  practical  utility,  including 
attention  to  the  skin,  lungs,  bowels,  and  digestion,  especially 
intestinal  digestion  and  absorption,  and  careful  regulation  of  the 
bowels,  avoidance  of  autointoxication  from  defective  elimination. 

The  Bad  Nauheim  (so-called  Schott)  method  of  systematic 
bathing  and  of  exercise  aga'  .st  gentle  resistance  would  seem  to 
find  its  widest  field  in  such  cases.  Even  where  the'  heart  has 
been  crippled  by  organic  disease,  however,  good  results  have 
been  produced.  We  would  certainly  regard  the  severer  exer- 
cise of  mountain-climbing  as  hazardous  in  the  extreme  in  or- 
ganic cases,  and  only  to  be  approached  by  easy  gradations,  to  be 
carefully  supervised  in  any  case.  Gentle,  largely  passive,  but 
always  carefully  regulated  exercises  will,  if  unaccompanied  by 
excitement,  prove  of  the  utmost  value. 

ORGANIC  CARDIAC  DISEASES. 

Pathology. — It  is  customary  in  works  on  pediatrics  to  rest 
content  with  the  statement  that  the  pathologic  changes  do  not 
differ  from  those  observed  in  adults,  but  as  the  early  periods  of 
life  so  often  mark  the  inception  of  these  dangerous  morbid 
processes,  a  concise  review  of  the  morbid  anatomy  will  not  be 
amiss. 

Sturges  is  inclined  to  speak  of  carditis,  believing  that  in  severe 
cases  the  morbid  changes  are  not  confined  to  the  endocardium 
or  pericardium,  but  that  these  structures  share  with  the  heart 
muscle  in  a  common  pathologic  process.  As  Crandall  remarks, 
however,  "these  cases  (of  Sturges')  came  to  autopsy,"  and  we 
can  not  feel  certain  that  such  diffuse  lesions  exist  in  most  cases. 
Certainly  disease  of  one  or  the  other  structure  usually  predom- 


ORGANIC    CARDIAC    DISEASES.  40 1 

inates,  just  as  the   croupous  pneumonia  will   far  outweigh  the 
small  amount  of  pleuritis  that  accompanies  it. 

Pericarditis. — Pericarditis  is  an  inflammation  of  the  serous 
covering  of  the  heart  and  of  its  reflection  on  the  inner  surface  of 
the  pericardial  sac.  We  may  divide  this  into  plastic  pericarditis, 
pericarditis  with  serous  or  purulent  effusions,  and  adherent  peri- 
carditis. The  changes  involved  may  be  only  different  stages  of 
one  morbid  process.  On  the  other  hand,  plastic  pericarditis  may 
subside  without  other  changes.  Effusion  may  come  on  insidi- 
ously. Purulent  pericarditis  probably  partakes  of  a  purulent 
nature  from  the  very  onset.  Adhesions  may  result  in  essen- 
tially chronic  cases,  in  which  there  has  been  no  suspicion  of  the 
process. 

In  plastic  pericarditis  the  internal  or  external  surfaces  of  the 
membrane  may  be  affected,  and  the  changes  local  or  general.  In 
the  mildest  cases  the  membrane  is  red,  sticky,  and  devoid  of  luster, 
the  latter  due  to  a  light  coating  of  fibrin.  The  fibrin  may  be  present 
in  such  large  amounts  that  the  "hairy  heart"  (cor  villoswri)  is 
produced.  Some  serous  exudate  is  always  found  between  the 
meshes  of  the  fibrin.  Many  of  these  cases  are  tuberculous,  the 
fibrin  covering  the  small  tubercles  (Osier).  If  resolution  occurs 
in  this  plastic  stage,  white  spots  are  seen  occasionally  to  dot  the 
serous  surface.  The  exudate  may  be  simply  serous,  containing 
flocculi  of  fibrin  and  endothelial  cells.  This  is  the  common 
form  of  effusion  in  rheumatic  endocarditis.  Again,  the  fluid 
may  be  purulent,  either  because  of  extension  from  the  contigu- 
ous mediastinal  glands  or  pleura,  as  a  manifestation  of  a  pyemic 
process,  or  as  a  primary  occurrence  (local  tuberculosis).  When 
the  fluid  is  bloody,  the  probabilities  are  that  the  affection  is 
tuberculous.  It  will  readily  be  seen  that  the  role  of  the  micro- 
organism in  pericarditis  is  a  most  important  one.  (See  Endo- 
carditis.) 

Adhesions  may  form  between  the  two  surfaces  of  the  mem- 
brane (local  or  general),  or  extrapericardial  adhesions  may  be 
present. 

Myocarditis,  an  inflammation  of  the  muscular  tissue  of  the 
heart,  results  whenever  pericarditis  is  well  marked.  For  a  depth 
of  two  to  three  millimeters  the  muscle  may  appear  quite  pale 
(Osier).  Affections  of  the  cardiac  muscle  in  childhood  have  not 
been  well  studied.  One  need  scarcely  more  than  allude  here  to 
the  common  forms  of  dilatation  and  hypertrophy,  whether  these 
lesions  occur  independently  or  are  accompaniments  of  valvular, 
pericardial,  kidney,  or  pulmonary  disease. 

In  pneumonia  and  diphtheria  cloudy  swellings  may  be  found, 
26 


4O2  DISEASES    OF    THE    HEART. 

and  in  typhoid  fever  a  true  myocarditis  may  be  present.  Tuber- 
cle and  syphilis  rank  as  uncommon  affections. 

Sarcomata  of  the  heart  are  exceedingly  rare. 

Endocardial  changes  may  also  accompany  the  aforemen- 
tioned process,  or  occur  without  either.  Micro-organisms  may 
be  found  in  lesions  of  the  lining  membrane,  and  yearly  their 
number  is  increasing.  We  quote  the  following  list  from  Wilson, 
though  it  is  by  no  means  exhaustive  :  Streptococci,  staphylo- 
cocci  (aureus,  albus,  cereus  albus,  flavus,  nonpyogenes),  the  ba- 
cillus typhi  abdominalis,  bacillus  tuberculosis,  bacillus  diphtheriae, 
bacillus  pyogenes  foetidus,  bacillus  of  anthrax,  the  micrococcus 
lanceolatus,  the  gonococcus  of  Neisser,  the  diplococcus  pneumo- 
niae.  In  many  of  the  cases  of  ulcerative  endocarditis  the  gono- 
coccus has  been  isolated  from  the  valvular  granulations.  We 
regard  the  list  as  very  important,  for  much  of  it  is  direct  evi- 
dence in  favor  of  the  infectious  character  of  acute  articular 
rheumatism,  and  tends  to  show  the  protean  nature  of  that 
disease.  Inflammation  attacks  most  frequently  the  valvular 
endocardium ;  in  intra-uterine  life  the  tricuspid,  and  in  post- 
natal existence  the  mitral,  leaflets  being  the  preferred  sites  of 
disease. 

The  changes  resulting  are  spoken  of  as  verrucose  (warty), 
ulcerative,  or  sclerotic ;  but,  as  in  pericarditis,  we  can  draw  no 
sharp  pathologic  or  clinical  lines. 

The  changes  occur  two  to  three  millimeters  from  the  free 
margins  of  the  leaflets  (Osier) — i.  e.,  at  the  lines  of  maximum 
contact  (Sibson).  In  the  verrucose  (warty)  form  small  bead-like 
bodies  or  larger  granulations  are  observed.  These  represent 
newly  formed  vascular  tissue  infiltrated  with  endothelial  cells  and 
capped  by  cellular  debris  and  fibrin.  Micrococci  are  present  in 
ulcerative  forms  (Eberth  and  Klebs),  but  are  known  to  bear  no 
constant  relation  to  the  simple  forms.  These  changes  commonly 
pass  into  a  sclerotic  phase,  with  the  tendency  to  contraction 
noticed  in  scar  tissue  generally.  Should  the  deformity  resulting 
narrow  the  valve  orifice  and  offer  resistance  to  the  normal  flow 
of  blood,  we  speak  of  stenosis  ;  should  the  valve  leaflet  fail  to 
meet  its  fellows  in  closure,  back  flow  or  regurgitation  would 
occur.  Sclerosed  valves  are  likely  to  be  the  seats  of  recurrent 
inflammations. 

More  rarely,  indeed  very  rarely  in  childhood,  the  warty 
granulation  undergoes  rapid  disintegration,  the  necrosed  tissue  is 
swept  away,  and  ulceration  or  malignant  endocarditis  manifests 
itself.  Such  an  ulcer  may  completely  perforate  a  valve.  Emboli 
are  sometimes  carried  along  into  the  circulation  in  the  various 


PERICARDITIS.  403 

forms  of  endocarditis,  and  the  resulting  phenomena  observed  in 
distant  parts  will  vary  according  to  the  structures  involved  and 
the  septic  or  nonseptic  characters  of  the  debris. 


DISEASES  OF  THE  PERICARDIUM. 

PERICARDITIS. 

Inflammation  of  the  serous  envelop  of  the  heart  may  occur, 
with  or  without  muscular  or  endocardial  involvement.  It  is 
properly  considered  a  disease  of  the  heart.  Large  effusions  are 
more  likely  to  occur  in  children  than  in  adults. 

Etiology. — Pericarditis  is  rarely  primary,  though  it  is  true 
that  the  pericardium  may  be  wounded  from  without,  and  that 
foreign  bodies  may  ulcerate  from  the  esophagus  into  the  sac. 

Rheumatism  is  the  most  frequent  cause  of  secondary  pericar- 
ditis, and  the  rheumatic  affection  may  be  so  slight  as  to  escape 
attention  ;  the  effects  of  the  poison  may  be  expended  upon  the 
pericardium  instead  of  on  the  joints.  Septic  infection  of  the  um- 
bilicus ranks  as  a  prominent  cause  in  early  infancy.  Tuberculous 
forms  of  pericarditis  are  much  more  common  than  is  usually 
supposed.  Scarlet  fever,  typhoid  fever,  diphtheria,  and  measles 
are  occasionally  the  essential  factors,  and  cases  following  in- 
fluenza are  reported,  but  it  is  difficult  to  exclude  antecedent 
lesions.  Pericarditis  may  be  met  accompanying  or  following 
many  grave  affections.*  Extension  of  inflammation  from  con- 
tiguous organs  occurs  in  a  number  of  cases  (pleuritis,  medias- 
tinal  abscesses,  pleuropneumonia). 

Pericarditis  may  occur  at  any  age,  and  males  are  more  fre- 
quently attacked  than  females. 

The  bacteriologic  findings  in  pericarditis  are  the  bacterium 
coli,  streptococci,  staphylococcus,  and  rarely  the  bacillus  pyocy- 
aneus.  It  is  common  to  find  it  accompanied  by  endocarditis. 

Symptoms. — The  forms  of  pericarditis  are  acute  and  chronic  ; 
these  are  again  divided  according  to  the  nature  of  the  inflamma- 
tion into  simple,  fibrinous,  or  plastic  inflammation  and  inflamma- 
tion with  effusion.  The  lesions  are  further  described  as  dry 
pericarditis,  when  the  inflammation  results  in  the  output  of  little 

*  Baginsky  met  with  pericarditis  purulentia  in  phlegmonous  erysipelas,  grave 
forms  of  angina,  caries  of  the  ribs,  fibrinous  pneumonia,  bronchopneumonia,  gastro- 
enteritis, furunculosis,  phlegmon  of  the  throat,  and  empyema. 


404  DISEASES    OF    THE    HEART. 

or  no  fluid,  or  it  is  absorbed,  leaving  behind  fibrinous  bands ; 
also  purulent  pericarditis,  when  the  fluid  is  infected  by  pus  from 
any  source.  Very  frequently  in  plastic  pericarditis  the  condition 
is  not  suspected  during  life.  Pain  referred  to  the  precordia  or 
to  the  xiphoid  cartilage  may  or  may  not  be  present.  There  may 
be  left  pleurothotonos — a  bending  of  the  body  to  one  side.  The 
pulse  is  usually  free  and  rapid.  Slight  fever  is  common,  and  a 
hacking  cough  is  often  present.  If  effusion  should  form  in  any 
considerable  amount,  sharp  or  stabbing  pain  may  be  complained 
of,  or  the  patient  simply  experiences  a  sense  of  discomfort  in  the 
precordial  region.  Here  tenderness  at  the  lower  sternum  may 
be  coupled  with  the  pain.  Dyspnea  is  common,  and  should 
always  demand  a  careful  examination  of  the  heart  and  lungs. 
The  face  may  be  dusky  and  the  expression  anxious.  The  patient 
is  restless ;  the  pulse  is  rapid,  small,  is  sometimes  irregular,  and 
the  pulsus  paradoxus  (failure  or  weakening  of  the  pulse  during 
inspiration)  may  be  observed. 

Pressure  on  the  recurrent  laryngeal  nerve,  when  present, 
causes  aphonia,  or  the  left  lung  may  become  physiologically 
hampered  from  the  pressure  exerted. 

Syncope,  hiccup,  insomnia,  and  low  delirium  are  present  in  the 
severer  cases  ;  or  marked  cerebral  symptoms  may  manifest  them- 
selves in  the  hyperpyrexia  of  rheumatic  sufferers. 

Effusions  may  come  on  insidiously,  and  with  practically  no 
symptoms  ;  if  abundant,  cyanosis  and  orthopnea  may  be  graphic 
features. 

In  adherent  pericardium  the  symptoms  are  uncertain  and  in- 
definite. The  affection  may  not  be  suspected  until  a  careful 
physical  examination  demonstrates  great  cardiac  enlargement. 

Physical  Signs. — Inspection  reveals  an  overacting  heart  in  the 
plastic  form  of  pericarditis.  When  effusion  takes  place,  the  pre- 
cordia bulges,  the  intercostal  spaces  become  prominent,  and 
edema  of  the  thoracic  wall  may  be  observed  (especially  when  pus 
is  present).  The  displaced  viscera  of  the  abdomen  may  produce 
a  prominence  in  the  epigastrium.  Systolic  retraction  at  the 
apex,  diffusion  of  the  apex-beat,  and  Friedreich's  sign  (diastolic 
collapse  of  the  cervical  veins)  are  of  diagnostic  importance  in 
adherent  pericardium.  Much  more  important  than  retraction 
anteriorly  is  the  posterior  retraction  described  by  Broadbent  and 
known  as  "  Broadbent 's  sign" 

Palpation  may  reveal  a  distinct  friction  fremitus  in  simple 
pericarditis,  most  marked  on  the  right  ventricle,  about  the  fourth 
interspace,  and  best  felt  as  the  patient  leans  forward.  As  effusion 
progresses  the  cardiac  impulse  becomes  weakened  and  finally 


PERICARDITIS.  405 

lost.  The  apex-beat  seems  displaced  upward  and  outward, 
though  this  is  probably  apparent  and  not  real.  At  the  same 
time  the  pulse  may  be  quite  forcible.  Fluctuation  can  rarely,  if 
ever,  be  detected.  When  adhesions  form,  systolic  retraction  can 
in  some  instances  be  felt  at  the  apex,  and  a  diastolic  rebound  may 
follow  it. 

Percussion. — In  simple  pericarditis  or  commencing  effusion 
we  can  expect  to  find  nothing  but  dullness  on  percussion.  As 
the  fluid  exudate  increases  the  precordial  area  of  dullness  becomes 
much  enlarged,  assuming  a  pear-shaped  type  with  the  base  di- 
rected downward  and  its  apex  toward  the  manubrium,  the  reverse 
of  normal.  Rotch  lays  great  stress  upon  the  enlargement  to  the 
right  of  the  sternum,  considering  this  diagnostic.  Sansom  finds 
a  small  posterior  area  of  dullness  important. 

Auscultation. — Most  pathognomonic  of  plastic  pericarditis  is 
the  friction  sound.  It  is  a  to-and-fro  or  double  sound,  corre- 
sponding to  systole  and  diastole,  but  outlasting  these  periods. 
Its  superficial  character  is  distinctive.  The  sound  usually  exhibits 
a  rubbing  or  grating  quality,  but  may  simulate  the  creaking  of 
new  leather  (bruit  de  cuir  neuf}.  It  is  usually  present  over  the 
right  ventricular  area,  but  may  be  noticed  at  various  sites.  It 
may  simulate  certain  valvular  murmurs,  but  does  not  follow  the 
laws  of  transmission.  When  fluid  appears  in  quantity  this  sound 
usually  disappears,  or  is  heard  only  in  certain  limited  areas. 
With  the  absorption  of  fluid  it  may  reappear.  In  large  effusions 
auscultation  over  the  left  lung  may  reveal  feeble  or  tubular 
breathing. 

In  chronic  adhesive  pericarditis  a  loud  systolic  murmur  may 
lead  to  an  error  of  diagnosis.  On  the  other  hand,  murmurs  are 
sometimes  absent.  The  fetal  rhythm  is  heard  when  marked  dila- 
tation is  present. 

The  pleuropericardial  friction  is  a  duplex  phenomenon  in  which 
altered  sounds  accompany  the  respiratory  as  well  as  the  cardiac 
movements. 

Diagnosis. — In  cases  of  frank  articular  rheumatism,  where  the 
heart  is  examined  daily,  the  onset  of  pericarditis  should  not  be 
difficult  to  recognize.  But  rheumatism  is  so  frequently  insidious 
in  the  child  that  this  cause  may  not  be  traceable.  Pericarditis 
complicates  other  affections,  and  as  the  pericardial  inflammation 
may  give  rise  to  very  little  disturbance,  the  affection  is  often  over- 
looked. When  effusion  is  excessive,  or  when  extensive  adhesions 
cripple  the  heart,  the  diagnosis  may  be  most  obscure. 

Cardiac  dilatation  or  hypertrophy  or  enlargement  of  the  heart 
from  any  cause  may  be  most  difficult  to  distinguish  from  peri- 


406  DISEASES    OF    THE    HEART. 

cardial  effusion.  In  the  course  of  time  the  Rontgen  rays  will  prove 
of  the  greatest  value  in  the  differentiation  of  these  two  conditions. 
A  weak  or  absent  apex-beat,  coupled  with  a  strong  pulse,  should 
strongly  suggest  effusion.  Again,  the  shape  of  the  dull  area  is 
of  great  importance,  being  increased  in  all  directions — in  the 
majority  of  instances  in  the  form  of  a  pear. 

In  dilatation  the  impulse  is  visible  and  wave-like  ;  it  is  scarcely 
visible  in  pericardial  effusion. 

The  double  murmur  of  aortic  valve  disease  may  simulate  a 
friction  sound. 

The  systolic  murmur  in  adhesive  pericarditis  may  be  difficult 
to  distinguish  from  a  valvular  murmur.  A  study  of  transmission 
and  quality  of  sounds,  over  various  portions  of  the  chest  will  here 
enable  us  to  differentiate.  Lastly,  certain  cases  of  massive  effusion 
may  be  most  difficult  to  diagnose,  as  they  simulate,  even  to  the 
tubular  breathing,  left-sided  pleural  effusion. 

When  purulent  pericarditis  is  suspected,  diagnostic  puncture 
should  be  performed.  A  temperature-range  peculiar  to  a  puru- 
lent process  and  a  study  of  the  blood  would  assist  the  observer. 

Prognosis. — This  depends  largely  upon  the  etiologic  factors 
and  upon  the  amount  of  effusion  and  whether  it  is'  serous  or 
purulent.  In  rheumatic  pericarditis  the  immediate  outlook  is 
usually  good,  though  these  cases  with  large  effusions  may  die 
suddenly  or  the  heart  be  subsequently  crippled  by  adhesive 
bands.  In  septic  or  purulent  pericarditis  the  prognosis  is  most 
gloomy.  Tuberculous  pericarditis,  though  slower  in  its  course, 
also  terminates  fatally. 

Treatment. — In  acute  pericarditis  the  child  must  be  kept  at 
absolute  rest  in  bed,  and  free  from  all  psychic  or  other  disturb- 
ances. This  condition  of  physical  and  mental  quiet  must  be  main- 
tained for  weeks  or  months.  Locally,  dry  cold  should  be  applied, 
as  this  suffices  to  lessen  the  cardiac  rate  and  vascular  pressure. 
Heat  (dry  or  moist)  may  supplement  this  with  much  comfort  and 
advantage  at  certain  times.  The  diet  should  be  simple  and  con- 
centrated, peptonized  foods  being  demanded  where  there  is  gas- 
tric disturbance  ;  all  gaseous  distention  must  be  promptly  relieved. 
The  systemic  treatment  will  depend  somewhat  upon  the  accom- 
panying and  causative  affection.  In  rheumatism  alkalies  com- 
bined with  the  salicylates  should  be  given,  unless  there  is  great 
depression.  In  septic  conditions  active  stimulation  is  demanded 
in  spite  of  the  pericardial  complication.  Morphin  is  the  stand-by 
to  relieve  pain  and  great  restlessness,  though  phenacetin  in  small 
doses  may  be  useful  in  mild  cases,  and  chloralamid  or  sulphonal 
will  control  restlessness  when  opium  is  not  demanded.  When 


r'O/  ,  /  //- 

OTHER    AFFECTIONS    OF    TKE    PEJlICA'kpjyM.  407 

'    / 1  • ,  f  '  J  \' 

the  inflammation  subsides  and  the  effusion,  appears  upon  the 
increase,  small  blisters  applied  over  the  precordia  at  internals  of 
seventy-two  hours  are  occasionally  very  useful.  Calomel,  alflne 
or  combined  with  Dover's  powder,  is  a  valuable  agent  here.  ,  A 
dose  or  two  of  a  saline  laxative  is  often  most  useful  in  robus-t 
children  or  sthenic  patients.  Potassium  iodid  is  recommended  in 
this  affection.  Caffein,  spartein,  or  diuretin  will  find  use  in  cer- 
tain cases.  Digitalis,  strophanthus,  and  convallaria  are  to  be 
used  only  when  there  is  marked  cardiac  weakness.  It  is  well  to 
begin  with  aromatic  spirits  of  ammonia  before  using  the  more 
powerful  cardiac  tonics. 

In  massive  effusion  paracentesis  should  be  performed,  either  in 
the  fifth  interspace,  slightly  to  the  left  of  the  sternum,  or,  as 
Rotch  suggests,  to  the  right  of  sternum.  In  serous  effusion  aspi- 
ration will  prove  sufficient,  but  where  pus  is  suspected,  a  surgeon 
should  always  be  called,  and  in  this  grave  affection  we  can  not 
regard  any  hopeful  operative  measure  as  too  radical.  Epilepti- 
form  seizures  or  choreiform  movements  may  appear  during  the 
operation  of  paracentesis. 

OTHER  AFFECTIONS  OF  THE  PERICARDIUM. 

Hydropericardium — a  collection  of  water  within  the  peri- 
cardium— in  the  child  is  quite  rare  ;  it  is  most  likely  to  occur  in 
kidney  disease,  and  more  rarely  (unaccompanied  by  other  drop- 
sical symptoms)  it  is  observed  after  scarlet  fever. 

Hemopericardium  (blood  within  the  pericardium). — The 
productive  factors  of  this  condition  in  adult  life  do  not  obtain  in 
the  child,  though,  as  already  mentioned,  tubercle  may  be  accom- 
panied by  sanguineous  pericardial  exudate. 

Pneumopericardium — air  within  the  pericardium — may  be 
produced  as  in  the  adult,  and  differs  in  no  way  from  the  condi- 
tion observed  in  adult  life. 


AFFECTIONS   OF   THE    MYOCARDIUM. 

Causes. — Hypertrophy  and  dilatation  usually  occur  con- 
jointly, and  may  result  from  excessive  cardiac  activity  per  se  ; 
mechanically,  from  extracardiac  adhesions  or  as  compensatory 
efforts  in  valvular  disease.  Nephritis  is  a  cause  of  left  ventricular 
hypertrophy.  (See  Fig.  36.) 

Symptoms  of  myocarditis  can  scarcely  be  separated  from 


\ N         \o - 

4O8  DISEASES    OF   THE    HEART. 

^H        -0 
those   of    accompanying    inflammatory    conditions.       Excessive 

dyspnea,  cyanosis,  and  palpitation  would  render  that  diagnosis 
probable.  Dilatation  and  hypertrophy  may  or  may  not  be 
accompanied  by  symptoms.  When  the  former  condition  far 
exceeds  the  latter  (dilatative  hypertrophy')  circulatory  phenomena 


FIG.  36. — ACUTE  PARENCHYMATOUS  NEPHRITIS  AND  HEMATURIA,  SHOWING  DECIDED  LEFT 
VENTRICULAR  HYPERTROPHY  ;  AREA  OF  DULLNESS  OUTLINED  BY  AUSCULTATORY  PER- 
CUSSION. 

arise,  which  will  be  recognized  as  evidences  of  failing  compensa- 
tion. 

In  syphilis  or  tubercle  we  should  expect  to  find  other  features 
or  signs  characteristic  of  one  or  the  other  disease. 


MYOCARDITIS. 

Myocarditis,  if  we  are  to  form  an  opinion  from  the  various  text- 
books, would  seem  to  be  one  of  the  rare  diseases  of  childhood. 
Judging  from  the  observations  made  at  autopsies,  where,  indeed, 
most  of  our  knowledge  of  the  pathology  and  theory  of  the  dis- 
ease is  obtained,  it  is  much  more  frequent  than  is  generally  sup- 
posed, and,  while  an  important  factor  in  the  symptomatology  of 


MYOCARDITIS.  409 

infectious  diseases,  it  is  not  so  fatal  as  the  literature  on  pediatrics 
would  lead  us  to  infer. 

Myocarditis  is  an  acute  or  chronic  inflammation  of  the  muscu- 
lar structure  of  the  heart.  The  chronic  form  is  always  found  in 
adults  and  associated  with  sclerosis,  and  therefore  will  not  be  dis- 
cussed here. 

Causes. — Myocarditis  is  either  primary,  when  due  to  diathetic 
dyscrasias — such  as  congenital  syphilis,  tuberculosis,  or  rheuma- 
tism ;  or  secondary,  when  due  to  endocarditis,  pericarditis, 
toxins  from  the  infectious  fevers,  or  poisons,  like  lead,  arsenic, 
or  phosphorus.  It  may  be  of  traumatic  origin.  Boys  are  much 
more  liable  to  be  affected  than  girls. 

Pathology. — Macroscopically  the  heart  muscles  are  pale,  soft, 
arid  friable  ;  microscopically,  changes  are  found  in  the  paren- 
chyma :  cloudy  swelling,  fatty  infiltration  and  fatty  degeneration, 
with  an  invasion  of  the  connective  tissue  by  leukocytes.  The 
whole  structure  of  the  heart  is  not  always  affected,  and  some  por- 
tions of  the  cardiac  tissues  may  be  quite  normal,  while  others  have 
become  degenerated.  The  myocardium  is  peculiarly  susceptible 
to  the  toxins  of  infectious  fevers  ;  the  fever  and  the  disease  itself 
may  seem  to  play  but  a  subordinate  part  in  fatal  cases.  This  is 
particularly  true  in  diphtheria  and  pneumonia,  where  the  severity 
of  the  toxemia  may  bear  no  or  only  a  small  relation  to  the  appar- 
ent mildness  of  the  disease.  Autopsies  in  diphtheria,  pneumonia, 
scarlatina,  and  typhoid  fever  constantly  show  sufficient  myocar- 
dial  changes  to  have  caused  death.  When  cloudy  swelling  and 
fatty  infiltration  have  occurred,  complete  recovery  may  follow,  but 
when  further  degenerations  have  invaded  the  tissues,  permanent 
injury  results.  The  former  conditions  are  constantly  found  in 
the  infectious  fevers. 

Symptoms. — The  symptoms  of  myocarditis  are  apt  to  be  lost 
sight  of  in  the  care  of  the  primary  disease,  if  indeed  any  are 
present.  Some  of  the  most  serious  cases  of  myocarditis  have 
been  evidenced  only  by  the  sudden  death  of  the  patient.  When, 
however,  faintness,  cyanosis,  vomiting,  dyspnea,  and  precordial 
pain  or  distress,  together  with  a  weak,  rapid,  irregular  heart 
action,  with  a  feeble  impulse  and  weak  sound,  are  present,  it  is  cer- 
tainly significant  of  myocarditis,  and  should  be  suggestive,  espe- 
cially when  associated  with  or  following  upon  the  infectious 
fevers.  In  these  cases  again  we  find  the  ratio  of  the  pulse  and 
respiration  distorted.  Dilatation  and  hypertrophy  may  or  may 
not  be  accompanied  by  symptoms.  When  evidences  of  failing 
compensation,  with  its  attending  circulatory  phenomena,  arise, 
eccentric  hypertrophy  can  be  recognized. 


4IO  DISEASES    OF    THE    HEART. 

Diagnosis. — The  diagnosis  of  myocarditis  is  most  often  made 
first  at  the  autopsy.  A  positive  diagnosis  during  life  is  generally 
impossible,  but  should  always  be  suspected  in  the  infectious 
fevers,  when  the  cardiac  symptoms,  before  mentioned,  are  present, 
especially  so  when  pericarditis  and  endocarditis  can  be  excluded. 

Treatment. — Absolute  rest  should  be  insisted  on,  especially 
following  severe  attacks  of  the  infectious  fevers,  when  myocar- 
ditis is  almost  always  a  coexistent  condition.  The  patient  should 
be  kept  in  a  recumbent  position  for  several  weeks,  and  prevented 
from  making  any  sudden  exertion,  which  might  prove  fatal. 
Cardiac  stimulants  like  ammonia,  alcohol,  caffein,  strychnin,  and 
iron  should  be  given.  Digitalis  should  be  used  with  caution  and 
only  when  evidences  of  muscular  failure  are  plain.  When  symp- 
toms of  heart  failure  appear,  morphin  hypodermically  may  be 
administered  with  gratifying  results.  Syphilitic  and  tubercular 
myocarditis  demand  appropriate  treatment. 

Sequelae. — Those  cases  where  cloudy  swelling  or  fatty  infil- 
tration only  has  taken  place  may  go  on  to  a  complete  recovery, 
when  the  heart  tissue  resumes  its  normal  condition.  In  extreme 
cases,  where  the  toxemia  has  been  intense,  heart  failure  may 
terminate  the  case ;  but  when  fatty  degeneration  has"  occurred, 
where  the  proper  nutrition  of  the  heart  muscle  has  been  inter- 
fered with,  there  is  a  permanent  structural  change.  This  results 
in  a  hypertrophy  and  dilatation,  and  may  even  proceed  to  an 
aneurysm  or  rupture  of  the  heart. 

Acute  suppurative  myocarditis,  or  abscess  of  the  heart,  is 
a  rare  condition  in  adults  or  children.  When  seen,  it  is  due  to  a 
phlebitic  or  pyemic  origin. 

Cardiac  aneurysm,  while  not  always,  is  generally  due  to  a 
true  myocarditis,  and  its  favorite  point  of  election  is  the  left  ven- 
tricle. It  may  reach  a  considerable  size.  Embolism  into  the 
coronary  artery  may  lead  to  this  condition  by  causing  a  necrosis 
of  the  tissues.  It  is  extremely  rare  in  children. 


DISEASES    OF   THE    ENDOCARDIUM. 

ENDOCARDITIS. 
Synonym. — VALVULITIS. 

Causes. — Rheumatism  is  by  far  the  most  frequent  cause  of 
endocardial  inflammation.  Chorea  is  frequently  accompanied 
by  endocardial  change,  but  here  again  the  underlying  cause  is 


ENDOCARDITIS. 


411 


probably  rheumatism  in  the  majority  of  cases.  Septic  conditions 
give  rise  to  endocarditis.  Pneumonia  and  pleuritis  are  frequent 
causes.  Scarlet  fever  is  too  often  complicated  by  endocarditis  ; 
and  diphtheria,  measles,  typhoid  fever,  and  variola  rank  as  occa- 
sional causes.  Tuberculous  endocarditis  occurs.  Endocardial 
changes  may  accompany  acute  or  chronic  nephritis.  Carcinoma 
is  so  rare  as  scarcely  to  demand  mention.  Lastly,  endocarditis 


FIG.  37. — GIRL  AGED  ELEVEN  YEARS;  DOUBLE  MITRAL  DISEASE,  AREA  OF  DULLNESS 
GREATLY  INCREASED,  ESPECIALLY  OVER  THE  LEFT  VENTRICULAR  REGION. 


recurrens,  rather  a  frequent  affection,  is  worthy  of  attention. 
According  to  Crandall,  girls  suffer  from  rheumatism  and  conse- 
quent valvulitis  much  more  frequently  than  boys.  Endocarditis 
may  occur  in  utero,  but  is  rare  under  five  years. 

Clinical  History. — Acute  endocarditis  maybe  cured — "  really 
cured  "  (Jacobi) — in  the  child,  but  too  often  the  acute  inflamma- 
tion ends  in  the  sclerotic  changes  previously  described,  and  we 


412  DISEASES    OF    THE    HEART. 

have  the  crippled  leaflets  of  chronic  valvular  disease.  This  may 
never  cause  any  inconvenience  in  the  subject  affected,  for  the 
muscular  walls  of  the  chamber  or  chambers,  which  must  stand 
the  brunt  of  strain,  undergo  a  true  hypertrophy. 

Thus,  in  partial  obstruction  at  the  mitral  valve  we  should  ex- 
pect left  auricular  hypertrophy.  In  regurgitation  at  the  sameorifice 
the  left  ventricular  wall  would  share  in  the  enlargement,  for  it 
must  now  exhibit  force  enough  to  send  an  increased  amount  of 
blood  in  two  directions.  This  same  ventricular  wall  would  hy- 
pertrophy in  the  common  combined  lesion  at  the  aortic  valve. 
Where  such  hypertrophied  muscle  adequately  performs  its  in- 
creased task,  compensation  has  been  effected.  Now,  if  the  heart 
muscle  of  the  left  side  fails  to  compensate  fully,  the  strain  comes 
upon  the  pulmonary  system  of  vessels,  and  certain  lung  symp- 
toms arise.  The  next  tissue  affected  would  be  the  right  heart ; 
and,  lastly,  the  strain  would  manifest  itself  in  back  pressure  upon 
the  venous  system.  Fortunately,  compensation  is  very  readily 
effected  in  the  child,  and  so  even  in  grave  endocarditis  children 
may  thrive  surprisingly.  We  must  not  forget,  however,  that 
recurrent  inflammation  is  common,  and  that  during  such  recur- 
rence some  acute  disease  or  physical  strain  may  serve  as  the  im- 
mediate determining  factor  of  failing  compensation. 

Practically,  then,  we  have  three  clinical  stages  of  endocarditis  : 
(i)  Acute  inflammation,  which  may  terminate  in  recovery,  death, 
or  chronic  valvulitis  ;  (2)  compensation  (in  chronic  valvulitis) ; 
(3)  failing  or  lost  compensation. 

Symptoms. — The  symptoms  of  acute  endocarditis  may  be 
obscure  or  wholly  wanting,  so  that  a  diagnosis  is  not  made  until 
permanent  damage  is  done.  When  it  arises  in  the  course  of  an 
acute  disease,  as  articular  rheumatism,  the  temperature  rises 
slightly  (i°  to  2°  F.),  the  pulse-rate  is  increased,  and  the  child 
is  restless,  with  anxious  expression.  Pain  and  palpitation  are 
rarely  experienced.  Cyanosis  may  appear,  especially  if  the  myo- 
cardium become  involved  (vide  supra}.  The  occurrence  of  fibrous 
nodules  around  joints  is  suggestive,  though  not  pathognomonic. 
Advanced  symptoms  are  seldom  seen  in  the  first  attack.  How- 
ever, there  are  certain  grave  cases  of  rheumatic  endocarditis 
which  are  attended  by  high  fever,  marked  constitutional  symp- 
toms, and  hemorrhages,  thus  making  one  think  of  ulcerative 
endocarditis  (Litten).  Lastly,  ulcerative  endocarditis  itself  is 
usually  accompanied  by  marked  cardiac  disturbance,  by  a  typhoid 
state,  by  purpura  and  hemorrhage  from  mucous  membranes,  and 
by  the  presence  of  embolic  abscesses  in  various  parts  of  the  body. 
Fortunately,  this  fatal  disease  is  rare  in  childhood. 


ENDOCARDITIS.  413 

If,  to  meet  the  damage  done,  compensation  is  fully  established, 
chronic  valvular  disease  may  be  devoid  of  symptoms  ;  but  if 
compensation  should  be  imperfect,  some  of  the  following  symp- 
toms are  liable  to  be  present :  Dyspnea  and  palpitatio)i  are  most 
common  in  aortic  disease  ;  pain  is  rarely  present,  except  in  mitral 
stenosis  ;  typical  ascending  edema  is  almost  never  seen  in  chil- 
dren, although  pulmonary  congestion  is  common  enough  ;  cpis- 
taxis  is  far  from  rare  ;  subacute  bronchitis  and  persistent  congJi  are 
frequent  accompaniments  of  chronic  valvular  disease.  Cyanosis 
and  venous  stasis  especially  accompany  mitral  regurgitation. 

Physical  Signs. — Acute  endocarditis  is  usually  diagnosticated 
by  the  physical  signs.  Inspection  shows  a  rapid  and  diffuse  car- 
diac beat.  Palpation  confirms  this  observation,  and  may  reveal 
a  strong,  somewhat  jerky,  or  irregular  pulse  (fiulsns  celer).  Per- 
cussion is  at  first  negative,  unless  some  preceding  disease  of  the 
heart  has  induced  a  change  in  its  volume.  The  signs  of  dijata- 
tion  appear  sometimes  with  astounding  rapidity.  On  ausculta- 
tion we  may  hear,  usually  at  the  cardiac  apex,  a  large  blowing 
systolic  murmur  or  souffle.  When  we  remember  that  the  local- 
ized damage  may  be  exceedingly  insignificant,  we  are  not  sur- 
prised that  physical  signs  occasionally  fail  us.  Osier  styles 
these  signs  "  notoriously  uncertain."  In  severe  cases  of  ulcera- 
tive  endocarditis,  however,  the  physical  signs  are  likely  to  be 
accentuated. 

In  chronic  valvular  disease  a  careful  and  judicial  study  of 
physical  signs  is  of  the  greatest  diagnostic  and  prognostic  im- 
portance. We  have  outlined  certain  limitations  in  the  study  of 
these  conditions  in  an  early  chapter ;  we  will  speak  of  others 
now,  but  these  need  not  discourage  us  from  carefully  studying 
every  case.  The  research  is  a  more  difficult  one  in  children  than 
it  is  in  adults,  but  it  is  still  a  fruitful  and  imperative  quest.  We 
have  no  more  patience  with  the  diagnostic  Nihilist  than  with  the 
therapeutic  brother  of  the  same  negative  type.  The  tools  at 
hand  are  simple  and  effective  in  each  instance  ;  one  has  simply 
to  acquire  a  practical  knowledge  of  their  judicious  use. 

We  shall  exclude  pulmonary  stenosis  from  our  consideration 
here,  as  it  is  almost  invariably  a  congenital  affection,  and  has  been 
described  as  such.  There  remain  for  our  study  mitral  regurgi- 
tation, mitral  stenosis,  aortic  regurgitation  or  double  aortic  dis- 
ease, and  tricuspid  regurgitation. 

Mitral  Regurgitation  or  Insufficiency. — The  leaflets  of  this 
valve  suffer  most  frequently  from  endocardial  inflammation,  and 
incompetency  (producing  regurgitation)  is  the  most  common 
result. 


414  DISEASES    OF    THE    HEART. 

Inspection  frequently  reveals  a  bulging  of  the  precordia.  The 
apex-beat  appears  diffuse  and  may  be  displaced  downward  and 
to  the  left.  The  cervical  veins  may  be  distended  and  occasion- 
ally they  exhibit  pulsation.  Palpation  furnishes  us  with  our  best 
means  of  locating  the  apex-beat,  and  this  is  usually  dislocated 
downward  and  to  the  left  (Sansom).  Pulsation  may  be  quite 
general  and  diffused,  felt  over  the  whole  left  ventricular  area,  and 
usually  over  the  right  ventricular  region. 

One  should  mentally  note  whether  such  pulsations  are  weak 
and  wavy  or  forceful.  A  systolic  thrill  is  sometimes  present,  as 
in  any  valvular  affection,  but  thrill  is  much  more  common  in 
mitral  stenosis. 

In  no  valvular  affection  does  percussion  reveal  so  broad  an  area 
of  dullness  as  in  well-marked  mitral  regurgitation.  The  dullness 
extends  to  the  left,  beyond  the  nipple-line,  possibly  to  the  axilla, 
and. to  the  right  as  far  as  the  right  sternal  border  or  beyond  it. 
But  percussion  should  not  be  performed  to  ascertain  the  size  of 
the  heart  alone  ;  percussion  reveals  most  when  it  informs  us  of 
the  sizes  of  the  various  chambers  of  the  heart  (Sansom).  Thus 
we  are  led  inductively  to  the  study  of  auscultation,  which,  though 
our  most  nearly  perfect  method  of  exploration,  is  often,  but  con- 
firmatory of  what  the  other  procedures  have  already  made  clear. 
Now,  murmurs  are  not  always  present  in  valvular  disease,  but, 
on  the  other  hand,  most  murmurs  in  childhood  are  organic. 
One  must  study  the  point  of  greatest  intensity  very  carefully,  for 
the  child's  chest  is  so  small  that  sounds  are  often  widely  diffused. 
The  murmur  of  mitral  regurgitation  is  almost  invariably  systolic 
in  time,  and  the  sound  continues  throughout  the  systole.  It  is 
heard  best  at  the  apex,  though  occasionally  the  base  or  midster- 
num  may  present  the  loudest  sound.  It  is  transmitted  to  the 
axilla  and  to  the  left  scapular  region.  The  quality  may  vary 
from  a  soft  cooing  murmur  up  to  a  harsh  rasping  or  sawing  char- 
acter. We  have  plainly  heard  this  murmur  with  the  examining 
ear  an  inch  from  the  chest.  Double  mitral  disease  is  rather  fre- 
quently observed. 

Mitral  Stenosis  or  Obstruction. — This  affection  is  much  less 
common  than  the  foregoing  lesion,  though  a  considerable  degree 
of  stenosis  may  accompany  regurgitation.  Mitral  stenosis  arises 
in  insidious  forms  of  rheumatism  (Sansom  ;  Crandall). 

Inspection. — Pulsation  may  be  observed  over  the  upper  chest 
upon  the  left  side.  Osier  states  that  this  is  due  to  right  ventric- 
ular hypertrophy,  no  matter  how  far  upward  and  to  the  left  it 
may  extend.  The  apex  appears  normally  situated  or  is  removed 
but  a  short  distance  from  its  usual  site. 


ENDOCARDITIS.  4  I  5 

Palpation  reveals  pulsation  over  the  left  auricular  area  and 
over  the  right  heart.  An  apical  presystolic  thrill  is  quite  com- 
mon. This  may  be  present  at  certain  times  and  not  at  others. 
It  is  usually  accentuated  by  an  upright  or  bending  forward  posi- 
tion. In  well-marked  instances  this  sign  is  practically  pathog- 
nomonic.  Careful  percussion  reveals  dullness,  extending  to  the 
right  and  in  an  upward  direction  to  the  left  of  the  sternum. 
Hypertrophy  is  seldom  so  marked  as  in  double  mitral  disease  or 
mitral  regurgitation.  The  murmur  of  mitral  stenosis  is  abso- 
lutely characteristic.  It  is  of  short  duration,  occurs  during  the 
presystolic  or  later  diastolic  period,  becomes  rapidly  intensified, 
and  ceases  with  the  systolic  impulse.  It  corresponds  in  time  to 
the  described  thrill.  It  is  best  heard  at  the  apex  or  in  the  fourth 
interspace  above.  Ordinarily  it  is  not  transmitted  to  any  degree, 
though  Griffith  has  observed  cases  where  this  murmur  was  heard 
in  the  axillary  region  and  back.  Our  studies  have  confirmed  the 
statement  that  the  area  of  the  murmur  is  singularly  restricted. 
Gallop  or  fetal  rhythm  is  rather  common  in  mitral  stenosis. 
Accentuation  of  the  second  pulmonic  sound  is  almost  invariably 
present.  The  murmur  described  above  is  singularly  inconstant : 
it  may  be  present  at  one  time  and  not  at  another,  so  that  too 
much  prognostic  expectation  should  not  be  founded  upon  its 
disappearance. 

Disease  of  the  Aortic  Leaflets. — As  alcoholism,  excessive 
and  continuous  muscular  strain,  and  acquired  syphilis  are  rarities 
in  childhood,  the  etiology  of  aortic  disease  must  differ  essen- 
tially from  that  of  the  adult.  Excluding  congenital  cases,  the 
disease  is  almost  invariably  due  to  rheumatism. 

In  aortic  regurgitation  or  insufficiency  inspection  reveals 
the  apex  dislocated  to  the  left  and  to  a  low  point  in  the  thorax. 
The  apex  has  appeared  as  low  as  the  eighth  interspace  in  this 
disease.  The  precordia  bulges  markedly  in  the  young  child, 
especially  over  the  left  ventricular  area.  The  arteries  in  the  neck 
are  seen  to  throb  violently,  and  the  brachials  often  plainly  exhibit 
the  phenomenon.  Even  the  radials  appear  to  fill  and  empty  alter- 
nately and  most  rapidly. 

Corrigan  or  Water-hammer  Pulse. — The  capillary  pulse  is 
another  phenomenon  of  aortic  regurgitation.  The  ophthalmoscope 
reveals  pulsation  of  the  retinal  arteries.  Palpation  confirms  the 
suspicion  of  a  downward  dislocation  of  the  apex-beat,  and  prob- 
ably a  throbbing  sensation  can  be  perceived  over  all  the  precor- 
dia. A  thrill  at  the  aortic  cartilage  or  in  its  vicinity  may  be  felt. 
The  pulse  is  of  the  Corrigan  or  "  water-hammer"  type  ;  this  is 
made  more  pronounced  by  elevating  the  arm.  Percussion  reveals 


4l6  DISEASES    OF    THE    HEART. 

a  much  enlarged  precordial  dullness,  both  absolute  and  relative, 
and  the  increase  in  the  longitudinal  diameter  predominates  over 
the  lateral  increase.  (See  Mitral  Regurgitation.)  The  left  ven- 
tricle may  be  alone  affected,  or  all  of  the  cavities  may  suffer 
alike  from  dilatation  and  hypertrophy  (cor  bovinwn). 

On  auscultation  over  the  affected  heart  one  hears  a  diastolic 
murmur  at  the  aortic  cartilage  (second  right  interspace).  The 
sound  is  usually  a  soft  bruit,  long  drawn  out.  Frequently  it  com- 
pletely replaces  the  valvular  click  of  the  sound,  though  this  is 
not  always  the  case.  It  is  transmitted  down  the  sternum  or 
toward  the  apex.  A  sharper  murmur,  systolic  in  time,  may  pre- 
cede the  regurgitant  murmur,  and  is  probably  produced  by 
roughening  of  the  leaflets ;  for  in  these  cases  the  valve  orifice  is 
so  dilated  that  stenosis  is  out  of  the  question. 

Double  Aortic  Disease. — While  regurgitation  is  not  always 
accompanied  by  stenosis,  yet  marked  stenosis  is  probably  accom- 
panied by  leakage  in  every  instance.  Thus  we  deem  it  proper 
to  speak  of  double  or  combined  aortic  disease.  Of  course,  one 
or  the  other  of  the  conditions  may  preponderate.  Marked  sten- 
osis is  exceedingly  rare  in  childhood  except  as  a  congenital  lesion. 
It  is  scarcely  necessary  to  mention  that  we  may  have  ,a  combin- 
ation of  aortic,  mitral,  and  tricuspid  disease. 

Inspection. — The  apex-beat  may  be  somewhat  displaced,  but 
not  nearly  so  much  as  in  the  regurgitant  lesion. 

Palpation. — A  somewhat  forceful  and  disseminated  beat  is 
usually  felt.  A  thrill,  systolic  in  time,  is  decidedly  characteris- 
tic. It  is  very  marked  over  the  base  of  the  heart  or  at  the  aortic 
cartilage. 

Percussion  shows  slight  enlargement  of  the  left  ventricle  (con- 
centric hypertrophy),  and  mayhap  also  involvement  of  the  right 
heart. 

Auscultation. — Unless  the  systolic  murmur  is  exceedingly  shrill 
and  harsh  ;  unless  it  is  heard  best  at  the  second  right  inter- 
space and  is  transmitted  into  the  large  arteries  of  the  neck  and 
axilla,  we  can  not  be  certain  of  aortic  stenosis.  The  diastolic 
murmur  is  not  always  present.  In  a  case  recently  seen  at  the 
Polyclinic  Hospital  the  aortic  sound  of  closure  was  perfect  and 
there  was  no  murmur  in  diastole.  Sometimes  a  typical  to-and- 
fro  murmur  is  heard.  (See  Aortic  Regurgitation  and  Pericarditis.) 

Tricuspid  Disease. — Regurgitation  is  the  only  lesion  worth 
considering,  as  stenosis  is  nearly  always  congenital  and  the 
patients  thus  affected  soon  die.  Regurgitation  at  this  orifice  is 
primarily  due  to  involvement  of  the  left  heart  or  to  pulmonary 
disease,  the  right  side  suffering  secondarily.  It  may  occur  in 


ENDOCARDITIS.  417 

chronic  bronchitis  or  in  congenital  bronchiectasis,  and  is  accom- 
panied by  systolic  pulsation  of  the  cervical  veins  and  pulsation 
of  the  liver.  Signs  of  right  cardiac  hypertrophy  are  demon- 
strated by  percussion. 

Auscultation. — The  murmur  is  heard  near  the  lower  portion 
of  the  sternum,  and  is  soft  in  character  and  systolic  in  time.  It 
may  be  impossible  to  distinguish  it  from  the  murmur  of  mitral 
regurgitation. 

Diagnosis. — If  in  every  case  of  rheumatism  and  in  cases  of 
infectious  disease  an  examination  of  the  heart  should  be  made 
daily,  the  diagnosis  of  acute  endocarditis  would  be  secured  more 
frequently.  In  pericarditis  the  friction  sound  should  serve  to 
differentiate.  Cases  of  ulcerative  endocarditis  are  frequently  mis- 
taken for  typhoid  fever ;  the  diagnosis  is  sometimes  very  diffi- 
cult, and  we  should  endeavor  to  exclude  all  diseases  with  simi- 
lar symptoms.  (In  a  case  at  the  University  Hospital  miliary 
tuberculosis  simulated  ulcerative  endocarditis.)  In  cases  of 
chronic  heart  disease  physical  signs,  carefully  weighed,  will  serve 
us  in  most  cases.  We  must  not  rest  content,  however,  with  the 
diagnosis  of  a  lesion,  but  must  also  appreciate  the  ratio  between 
hypertrophy  and  dilatation,  and  must  study  carefully  the  general 
condition  of  the  patient. 

Prognosis. — In  acute  endocarditis  the  prognosis  is  usually 
good.  In  the  severe  recurrent  types  we  must  judge  of  severity 
by  the  amount  of  myocarditis  and  the  intensity  of  the  symptoms 
that  have  been  detailed.  In  ulcerative  endocarditis  the  prognosis 
is  absolutely  gloomy. 

In  chronic  cardiac  disease  the  quasi-scientific  man  blunders 
most  miserably.  Let  him  not  assume  that  the  presence  of  a 
heart  murmur  is  necessarily  of  dark  portent,  nor  that  it  should 
be  used  as  a  bugbear  during  the  remainder  of  the  patient's  exis- 
tence. Judge  carefully  of  the  amount  of  enlargement  of  the 
heart ;  try  to  estimate  whether  hypertrophy  is  present  to  a 
compensatory  degree.  Above  all,  do  not  forget  that  one  is  called 
upon  to  pronounce  an  opinion  upon  a  patient  and  not  upon  a 
heart.  Recurrent  rheumatic  attacks,  poor  hygienic  surroundings, 
lowered  nutrition,  puberty,  etc.,  are  damaging  factors.  On  the 
other  hand,  the  maintenance  of  perfect  nutrition  and  of  perfect 
cardiac  compensation  may  obtain  for  many  years.  The  outlook, 
in  the  presence  of  good  general  conditions,  is  almost  always 
bright  for  the  child.  It  will  be  most  unfavorable  in  aortic  incom- 
petency,  especially  if  failing  compensation  be  present,  somewhat 
better  in  mitral  stenosis,  best  in  mitral  regurgitation. 
27 


41 8  DISEASES    OF    THE    HEART. 

Treatment. — In  acute  endocarditis  our  first  effort  must  be 
directed  toward  minimizing  the  amount  of  work  done  by  the 
affected  heart.  Perfect  rest  to  body  and  mind  is,  if  anything,  of 
more  importance  than  in  pericarditis.  The  child  should  be  placed 
in  bed  and  kept  there,  unless  excessive  fretfulness  forbids,  when 
the  nurse's  arms  or  a  comfortable  lounge  may  serve  in  good 
stead.  The  diet  should  be  light,  digestible,  and  given  in  small 
amounts  and  at  rather  frequent  intervals.  Milk  will  prove  the 
best  food.  If  it  produces  flatulency,  predigestion  or  dilution  or 
both  should  be  employed. 

Acute  diseases  of  the  heart,  as  a  rule,  are  inflammatory ;  but 
not  always.  In  many  conditions  where  the  cardiac  disease  is 
a  frequently  occurring  complication,  as  in  diphtheria,  the  danger 
is  from  a  parenchymatous  myocardial  degeneration.  This  is  true 
also  in  children  during  attacks  of  the  exanthemata,  in  pertussis, 
and  in  pneumonia.  Here  the  deaths  are  due  primarily  to  the 
involvement  of  the  heart  muscles,  which  are  sometimes  fatally 
weakened  by  the  toxins  of  these  infections  without  giving  any 
discoverable  signs  of  carditis.  In  them,  too,  a  specific  softening 
and  consequent  destructibility  or  acute  structural  dilatation  of 
the  myocardium  generally  takes  place,  which  may  be  only,  or 
best,  revealed  by  percussion.  Evidences  of  a  general  failure  in  the 
circulation  must  not  be  overlooked.  Overexertion  after  the  con- 
tinued fevers  is  a  fertile  source  of  cardiac  damage  of  the  same 
character  as  that  following  prolonged  and  severe  strains  upon 
the  normal  heart. 

In  inflammatory  cardiac  conditions  there  is  great  excitement 
of  the  heart ;  the  muscle  is  in  ceaseless  activity,  and  during  this 
period  it  is  doing  twice  as  much  work  as  in  health  ;  hence  every 
effort  must  imperatively  be  made  to  maintain  absolute  rest  of 
mind  and  body  in  every  form  of  carditis. 

It  is  clear  that  at  this  stage  no  tonic  medication  is  of  use,  but 
only  quieting  agents  are  indicated.  If  pain  is  present,  clearly 
evidenced  or  to  be  elicited  by  pressure  under  the  left  costal  arch, 
along  with  hurried  breathing,  rapid  pulse,  disturbed  rhythm,  with 
or  without  murmurs,  the  treatment  should  be  external  applica- 
tions which  will  give  comfort  and  quiet  to  the  heart,  such  as  hot 
poultices  of  linseed  meal,  to  which  may  be  added  laudanum  or 
belladonna.  Local  blood-letting  by  leeches  applied  to  the 
sternal  notch,  thus  causing  a  reflex  nerve  sedatation,  produces 
much  relief  in  older  children.  The  ice-bag  to  the  chest  will 
prove  a  useful  local  measure,  especially  if  pain  is  present.  When 
the  heart  is  acting  well  and  good  compensation  has  been 
established,  as  shown  not  only  by  the  normal  position  of  the 


ENDOCARDITIS.  419 

apex-beat  but  also  by  the  absence  of  signs  of  backward  pressure 
in  the  lungs,  liver,  etc.,  drugs  that  would  further  stimulate  the 
heart  are  obviously  harmful.  If  the  physical  signs  are  not  asso- 
ciated with  any  evidence  of  failure  of  the  cardiac  muscles,  the 
effect  of  routine  treatment  by  digitalis  upon  the  heart  would  be 
to  drive  the  myocardium  to  increased  effort ;  the  endeavor  of  the 
right  ventricle  to  force  the  blood  through  the  lungs  more  rapidly 
might  possibly  lead  to  hemorrhage  from  the  pulmonary  capilla- 
ries, and  the  left  auricle  as  well  as  the  right  ventricle  would  prob- 
ably further  dilate. 

Treatment  should  be  directed  to  the  maintenance  of  the  bal- 
ance in  the  circulation  by  judicious  advice  as  to  the  manner  of 
life  to  be  led  and  the  attention  to  the  general  health.  The  heart 
should  be  carefully  examined  at  intervals,  especially  when  any 
signs  of  downward  progress,  such  as  increased  or  increasing 
dilatation  or  engorgement  of  the  liver  and  lungs,  begin  to  make 
their  appearance.  If,  however,  these  symptoms  show  themselves, 
now  is  the  time  of  all  others  that  drugs  of  the  digitalis  group 
are  indicated  and  form  a  necessary  factor  in  the  treatment.  As 
a  preliminary  to  the  use  of  digitalis  a  free  purgative  is  very  use- 
ful, and  leeches  to  the  precordia,  or  even  venesection,  may  with 
advantage  be  resorted  to  when  there  is  cyanosis.  The  effect  of 
these  remedies  upon  the  heart  and  circulation  should  be  care- 
fully watched.  When  larger  doses  of  digitalis  are  called  for,  it 
is  well  to  restrict  the  patient  to  the  recumbent  position. 

There  is  a  most  intimate  vasomotor  association  between  the 
nerves  which  contract  the  blood-vessels  of  the  viscus  and  the 
cutaneous  nerves  of  the  corresponding  skin  area  thereabouts 
(W.  H.  Thomson). 

Systemically,  in  rheumatic  cases  we  should  use  the  salicy- 
lates  alone  or  combined  with  alkalies — strontium  salicylate  is 
perhaps  the  best.  These  should  never  be  used  long  at  a  time, — 
not  over  two  or  three  days  continuously, — for  it  is  quite  gener- 
ally recognized  that  endocarditis  is  an  incident  and  not  a  com- 
plication in  the  course  of  rheumatism.  Jacobi  lays  great  stress 
upon  the  use  of  potassium  iodid.  Phenacetin  is  also  a  helpful 
drug,  and,  aside  from  its  effect  upon  the  fever  and  pain,  is  prob- 
ably antirheumatic.  The  bromids  are  useful  to  control  restless- 
ness. In  serious  cases,  attended  by  great  pain  and  restlessness, 
opium  is  again  the  remedy  par  excellence.  Alcohol  and  cardiac 
stimulants  are  contraindicated  in  simple  cases.  The  bowels 
must  be  kept  rather  freely  open  by  the  use  of  mild  laxatives  or 
enemata. 

If  a  surface  pallor  with  a  small,  rapid,  irregular  pulse  is  noticed, 


42O  DISEASES    OF    THE    HEART. 

it  may  be  the  result  of  a  myocarditis  and  arterial  degeneration 
due  to  the  toxic  effects  of  the  exanthemata  and  diphtheria. 
Digitalis  is  then  of  no  use,  because  it  will  not  benefit  the  degen- 
erated muscles,  but  rather  requires  a  fairly  normal  muscle  to 
work  upon.  Here  strychnin  is  a  far  better  agent,  along  with 
some  alcohol.  The  hypodermic  use  of  camphor  is  also  of  ser- 
vice ;  three  to  eight  grains  may  be  given  in  sterile  oil  to  a  child 
of  five. 

When  the  more  protracted  effects  of  an  endocarditis  are  pres- 
ent, it  is  well  to  insist  upon  several  weeks  of  absolute  rest. 
There  may  be  much  relief  thus  afforded  to  the  inflammatory 
vegetations  which  tend  to  form  on  the  valves  and  flaps,  by  keep- 
ing the  circulation  as  quiet  as  possible,  otherwise  there  is  danger 
of  adhesions  with  contractions  of  the  delicate  endocardial  struc- 
tures. 

In  septic  cases  (ulcerative  endocarditis)  stimulants  must  be 
used  with  a  free  hand  in  spite  of  their  local  effects  on  the  heart. 

After  a  pericarditis  "it  sometimes  happens  that  the  inflamma- 
tion extends  to  adjacent  structures,  such  as  the  pleura,  ribs,  or 
sternum,  and  adhesions  result.  Here  mechanical  measures  are 
useful,  such  as  strapping  the  left  side  with  strips  of  rubber  plas- 
ter, in  order  to  limit  the  full  force  of  the  systole  and  assist  in 
maintaining  tranquillity.  If  there  is  pain  also,  heat  or  cold  may 
be  used,  along  with  belladonna  or  laudanum  externally. 

It  is  in  chronic  heart  disease  that  ardent  therapy  may  carry 
havoc  in  its  path.  These  cases  should  be  recipients  of  hygienic 
care,  as  regards  diet,  bathing,  exercise,  and  rest ;  and  children 
should  be  guided  into  such  life  pursuits  as  will  minimize  the 
demands  of  physical  efforts  and  strains.  It  will  be  well  for 
every  student  to  read  Jacobi's  sound  advice  in  his  most  excellent 
book  on  "  Therapeutics  of  Childhood."  If  compensation  is 
adequate,  the  heart  needs  no  drug  to  whip  it  on  to  increased 
endeavor  and  consequent  disturbance  of  balance.  Some  mem- 
ber of  the  family  who  will  aid  us  in  enforcing  proper  hygienic 
and  other  limitations  must  be  informed  of  the  cardiac  condition. 
Lastly,  each  case  must  be  judged  on  its  own  individual  indica- 
tions, and  our  efforts  must  be  largely  guided  by  results  obtained. 
When  the  cardiac  balance  is  disturbed,  once  more  rest  must  be 
enjoined.  Often  this  masterly  inactivity  alone  will  prove  suffi- 
cient to  reestablish  the  equilibrium  so  necessary  to  secure  in 
such  cases.  When  cyanosis,  dropsy,  pulmonary  congestion,  or 
other  serious  symptoms  arise,  digitalis  is  by  far  the  best  drug 
at  our  command.  It  may  be  used  irrespective  of  lesion,  though 
it  probably  does  best  in  mitral  regurgitation.  The  infusion 


ENDOCARDITIS.  42 1 

is  the  best  preparation,  and  may  be  given  in  doses  of  from 
twenty  minims  to  one  fluidram,  or  more,  according  to  the  age  of 
the  child.  Strophanthus  may  be  used  where  symptoms  of  digi- 
talis poisoning  arise  or  where  digitalis  can  not  be  given.  Spar- 
tein,  caffein,  convallaria,  nitrites,  etc.,  are  indicated  in  certain 
cases,  but  they  are  all  vastly  inferior  to  digitalis.  Digitalis  may 
be  given  for  weeks,  or  even  months,  until  compensation  is  re- 
stored. Iron  will  prove  of  great  value  during  and  after  conva- 
lescence. Strychnin  in  small  tonic  doses  is  especially  useful 
when  the  myocardium  is  weakened.  Cod-liver  oil  may  also  be 
of  use. 

There  comes  a  time  in  subacute  and  chronic  disease  of  the 
heart  when  carefully  systematized  exercises,  such  as  breathing, 
posturing,  and  later  passive  and  slightly  active  movements,  are 
of  great  utility  to  improve  the  circulation  and  maintain  vigor, 
both  mental  and  physical. 


CHAPTER  XIII. 

DISEASES  OF  THE  RESPIRATORY  ORGANS. 


DISORDERS    OF   THE    UPPER    RESPIRATORY 

TRACT. 

Diseases  of  the  upper  respiratory  tract  are  common  in  children, 
and  their  early  treatment  is  especially  important,  for  when  neg- 
lected, disastrous  effects  follow  upon  the  health  and  development 
of  the  child. 

Inasmuch  as  the  treatment  of  many  of  these  affections  is  largely 
surgical,  it  requires  a  special  knowledge  and  training  on  the  part 
of  the  physician.  A  description  of  the  various  operations  and 
instruments  would  be  out  of  place  here.  It  will  be  our  endeavor, 
however,  to  give  a  brief  description  of  the  principal  affections, 
with  general  suggestions  for  their  treatment. 

Causes  and  Pathology  of  Diseases  of  the  Upper  Respira- 
tory Organs. — In  a  brief  article  on  nasal  diseases  of  infancy  and 
childhood  it  is  well  to  confine  ourselves  to  generalities,  and  to 
mention  merely  the  more  important  causes  which  produce  the 
pathologic  changes  in  the  upper  respiratory  tract  in  children,  and 
the  immediate  consequences  of  these  pathologic  changes  in  their 
effect  on  the  growth  of  the  nasal  organs,  producing  a  change  of 
development  in  the  whole  system  of  the  child. 

Among  the  chief  causes  of  nasal  disease,  and  particularly  of 
nasal  obstruction,  are  infection  from  any  source,  want  of  cleanli- 
ness in  early  life,  and  climatic  and  temperature  influences,  caus- 
ing the  ordinary  acute  coryza  of  infancy.  From  whatever  cause, 
the  result  is  a  swelling  of  the  mucous  tissues  and  a  diminution 
in  the  amount  of  the  secretion.  For  this  reason  the  solid  ele- 
ments seem  to  be  more  abundant,  causing  the  ropy,  tenacious, 
and  mucopurulent  character  of  the  nasal  discharges.  This  ob- 
structive pathologic  change  necessarily  interferes  not  only  with 
the  proper  respiration,  but  also  with  nutrition  of  the  infant,  inas- 
much as  suckling  from  either  nipple  or  bottle  is  impossible  when 
the  nose  is  obstructed.  If  nothing  is  done  toward  reducing 
the  swelling  and  inflammation  within  the  nasal  cavities,  a  state 

422 


DISORDERS    OF    THE    UPPER    RESPIRATORY    TRACT.  423 

of  subacute  and,  later,  of  chronic  inflammation  and  tumefaction 
of  the  turbinates  ensues,  the  normal  development  of  the  nasal 
organs  is  interfered  with,  and  deformities  result. 

In  order  to  understand  this  more  thoroughly  we  must  remember 
that  in  the  new-born  there  are  four  turbinated  bones  on  each  side, 
and  that  the  vertical  division  (septum)  between  the  anterior  nasal 
cavities  is  entirely  composed  of  cartilage,  which  gradually,  as  the 
child  grows  older,  is  displaced  in  its  posterior  portion  by  the  per- 
pendicular plate  of  the  ethmoid.  This  in  its  descent  pushes  the 
anterior  cartilaginous  plate  forward,  and  thus  produces  the  well- 
marked  outline  of  the  nose  in  later  childhood  and  adolescence, 
which  in  infancy  is  so  ill  defined.  At  the  same  time  with  the 
progress  of  the  formation  of  the  bony  portion  of  the  septum  a  union 
takes  place  between  the  two  upper  and  the  two  lower  turbinated 
bones  respectively,  and  consequently  we  have,  by  the  time  the  indi- 
vidual has  reached  adolescence,  two  turbinated  bones  instead  of 
four,  as  in  infancy,  although  there  may  be  a  rudimentary  projec- 
tion high  up  in  the  nasal  chambers  which  corresponds  to  the 
rudimentary  fifth  turbinated  bone  of  infancy. 

Together  with  the  growth  of  the  septum  and  the  union  of  the 
turbinated  bones  the  other  bones  of  the  skull  and  face  enlarge, 
and  it  is  easy  to  see  that,  as  they  are  joined  each  to  the  other  in 
so  intricate  a  fashion,  any  lack  of  growth  or  interference  with  de- 
velopment of  one  bone  must  necessarily  exert  a  distorting  influ- 
ence upon  the  others.  It  is  thus  that  want  of  development  of  the 
bones  forming  the  nasal  cavities  will  cause  a  want  of  expansion 
of  the  dental  arch,  preventing  space  for  the  incisors,  causing  the 
jaw  to  assume  a  plowshare  shape  and  the  teeth  often  to  overlap. 
Such  want  of  development  of  the  dental  plates  of  the  superior 
maxillary  bones  is  always  observed  when  nasal  obstruction  has 
been  present  in  infancy.  But  it  is  not  only  the  development  of 
the  face  which  is  interfered  with  by  obstructive  nasal  disease  :  the 
child  is  deprived  not  only  of  its  nourishment,  but,  equally  im- 
portant, of  its  means  of  sustenance — namely,  sufficient  oxygen  in 
the  act  of  respiration.  This  deficiency  of  oxygen  is  an  indirect 
result  of  nasal  obstruction.  It  might  be  supposed  that  the  child, 
although  a  mouth-breather,  would  be  able  to  take  in  a  sufficient 
supply  of  oxygen  for  all  demands  of  the  system  ;  but  this  is  not 
so.  The  nose  is  the  true  organ  of  respiration,  because  it  is  sup- 
plied with  the  necessary  apparatus  for  warming,  filtering,  and 
moistening  the  air  before  it  enters  the  larynx,  trachea,  and  lungs. 
When,  therefore,  the  nose  being  obstructed  the  child  breathes 
through  the  mouth,  the  cold,  dusty,  and  dry  air  impinges  on  the 
membrane  of  the  larynx,  causing  inflammation  and  oftentimes  a 


424  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

hacking  cough.  When  the  air  reaches  the  smaller  bronchioles, 
the  irritation  causes  spasmodic  contraction  of  the  smaller  bronchi 
and  air  vesicles  of  the  lungs,  so  that  only  a  portion  of  the  lung 
tissue  is  inflated,  and  comparatively  little  oxygen  is  supplied  to 
the  system.  This  is  especially  noticeable  in  the  apices  of  the 
lungs,  where  the  bronchioles  become  very  small  and  attenuated, 
and  it  is  there  we  look  for  disease  of  the  lungs  in  its  first  stages. 
But  long  before  the  lungs  become  diseased  by  the  inadequate 
preparation  of  the  inspired  air,  due  to  nasal  obstruction,  the 
more  proximate  portions  of  the  respiratory  tract  exhibit  disturb- 
ance. If  we  review  the  diseases  of  the  upper  respiratory  tract 
in  infancy  and  childhood  and  endeavor  to  trace  the  etiology  of 
each  one  of  them,  we  shall  be  compelled  to  ascribe  the  ultimate 
cause  of  each  to  a  greater  or  less  degree  of  nasal  obstruction  or 
complete  stenosis.  By  stenosis  we  mean  complete  occlusion  of 
the  nares  to  both  inspiration  and  expiration,  while  by  obstruction 
is  meant  a  narrowing  of  these  channels,  one  or  both,  which  does 
allow  a  small  current  of  air  to  pass.  Complete  stenosis  is,  how- 
ever, but  rarely  met  with  in  infancy  and  childhood,  and  is  then 
caused  either  by  neoplasms  filling  the  nasal  or  postnasal  cham- 
bers or  by  a  congenital  malformation  of  the  nasal  bones,' most  fre- 
quently observed  as  obliteration  of  the  posterior  nares  by  a  thin 
slate  of  bone  projecting  across  their  posterior  orifices.  Partial 
stenosis  or  obstruction  of  the  nasal  chambers  is,  on  the  other 
hand,  quite  frequently  met  with  in  infancy  and  childhood,  and  is 
due  to  a  variety  of  causes.  First,  and  most  frequently  observed, 
is  the  obstruction  caused  by  temporary  and,  later,  permanent 
swelling  of  the  tissues  covering  the  lower  turbinated  bones.  This 
tumefaction  of  tissue  may  be  caused  by  specific  infection  from 
the  mother  during  delivery,  or  by  exposure  of  the  child  to 
extreme  changes  of  temperature,  producing  what  is  commonly 
called  a  cold  in  the  head  or  the  "  snuffles."  In  addition  to  the 
swelling  a  thickening  of  the  normal  watery  secretion  of  the 
organ  results  from  the  congestion,  and,  by  its  retention  in  the 
form  of  a  thick,  tenacious  flake,  adds  considerably  to  the  obstruc- 
tion. It  must  also  be  remembered  that  the  tissue  underlying 
the  mucous  membrane  covering  the  turbinates  is  composed  of  a 
network  of  blood-vessels  which  becomes  distended  and  enor- 
mously enlarged  by  the  stimulus  of  an  inflammatory  process  in 
the  immediate  neighborhood.  If  this  inflammatory  process  is 
not  speedily  checked  and  the  membrane  and  secretions  restored 
to  their  normal  state,  we  soon  have  a  chronic  catarrhal  condition 
and,  in  consequence,  more  or  less  permanent  obstruction  to  res- 
piration. A  less  frequent  cause  of  nasal  obstruction  in  children 


THF 


DISORDERS    OF    THE    UPPER    RESPIRATORY    TRACT."  " 

is  deviation  of  the  nasal  septum,  which  may  be  due  to  trauma- 
tism,  falls  or  blows  upon  the  nose,  or  it  may  be  caused  by  the 
pressure  of  a  hypertrophy  of  the  lower  turbinated  body  pushing 
the  cartilage  toward  the  opposite  nasal  chamber.  Still  another 
cause  of  impaired  nasal  respiration  is  the  introduction  of  foreign 
bodies  into  the  nose.  They  are  usually  introduced  by  the  child 
itself,  unknown  to  the  parents,  and  give  rise  to  symptoms  of  cold 
in  the  head,  with  copious  mucopurulent  discharge,  which  may 
be  tinged  with  blood.  Later  the  symptoms  are  those  of  hyper- 
trophic  catarrh,  with  the  addition  of  an  offensive  discharge.  The 
ordinary  mucoid  polypi  which  produce  nasal  obstruction  are 
seldom,  if  ever,  met  with  in  infancy,  but  are  not  uncommon  in 
later  childhood,  and,  by  the  increasing  pressure  during  their 
growth,  produce  in  time  noticeable  deformity  by  a  flattening  and 
spreading  of  the  upper  portion  of  the  back  of  the  nose. 

Mouth-breathing  is  injurious  because  the  inspired  air  is  not 
cleansed,  moistened,  or  warmed  as  it  is  in  normal  nasal  breath- 
ing, and  the  result  is  irritation  of  the  mucous  membrane  of  the 
pharynx,  larynx,  trachea,  and  bronchi,  which  is  readily  lighted 
up  into  acute  inflammation  by  cold  or  other  systemic  disturbance. 
Mouth-breathing  kept  up  for  a  long  period  of  time  results  in 
chronic  inflammation  of  the  mucous  membrane  of  the  respiratory 
tract,  favoring  in  children  the  formation  of  laryngeal  neoplasms. 
The  tonsils,  both  faucial  and  pharyngeal,  suffer  from  the  same 
cause,  and  acute  inflammation  and  hypertrophy  of  the  tonsils 
result.  More  serious  yet  is  the  fact  that  the  concomitant  inflam- 
mation of  the  upper  air-passages  in  the  exanthematous  diseases 
is  enormously  aggravated  by  the  nasal  obstruction,  while  the 
irritation  of  the  bronchioles  by  the  dry  and  dust-laden  air  pre- 
vents its  entrance  into  the  lungs  in  sufficient  quantities  for  the 
requirements  of  the  system,  and  thus  not  only  does  the  whole 
economy  suffer,  but  the  foundation  of  lung  disease  is  often  thus 
laid  in  early  childhood. 

On  the  other  hand,  it  not  infrequently  happens  in  scrofulous 
children  that  a  specific  or  nonspecific  acute  rhinitis,  instead  of 
resulting  in  permanent  hypertrophy  of  the  turbinated  tissues,  is 
followed  by  an  atrophy  of  not  only  the  mucous  membrane,  but 
also  of  the  turbinated  bones,  and  the  serous  as  well  as  mucous 
glands  embedded  in  the  membrane.  Such  a  condition  interferes 
in  the  same  degree  with  normal  respiration,  and  produces  perni- 
cious effects  upon  the  whole  respiratory  tract  and  the  system  at 
large,  as  does  nasal  obstruction.  The  nasal  chambers  become 
too  large  from  the  shrinking  of  the  tissues,  so  that  the  air  cur- 
rent can  not  be  properly  warmed  in  its  passage,  and,  the  glands 


426  DISEASES    OF   THE    RESPIRATORY    ORGANS. 

becoming  atrophied,  the  air  can  not  be  properly  moistened  and 
filtered,  so  that  we  have  the  same  conditions  as  in  mouth- 
breathing.  But  to  all  this  must  be  added  the  formation  of  large 
adhesive  scabs  in  the  nasal  chambers,  which,  by  their  bulk,  cause 
obstruction  ;  by  their  presence  as  foreign  bodies,  irritation  ;  and 
by  their  adhesiveness,  denude  the  membrane  of  its  epithelium  and 
cause  hemorrhage  at  their  expulsion  ;  and  by  their  putrefaction 
give  rise  to  the  well-known  and  offensive  odor  of  ozena.  The 
latter  fact  increases  the  danger  from  this  kind  of  nasal  catarrh  to 
the  system  at  large,  because  of  the  volatile  products  of  putrefac- 
tion which  are  carried  into  the  lungs  during  respiration. 


ACUTE  RHINITIS. 
Synonym. — CORYZA. 

It  is  hardly  necessary  to  describe  the  symptoms  of  this  very 
common  affection.  In  the  beginning  there  is  dilatation  of  the 
blood-vessels  of  the  mucous  membrane,  followed  by  swelling  of 
the  turbinated  bodies  and  a  discharge  of  mucus  and  serum. 
Later  the  discharge  becomes  thicker,  mucopurulent,  and  tends 
to  clog  the  nasal  passage.  This  condition  is  brought  about  by 
an  invasion  of  the  mucous  membrane  by  micro-organisms.  The 
vitality  of  the  tissues  may  be  temporarily  lowered  by  sudden 
chilling.  While  in  this  state  they  can  be  attacked  by  the  various 
bacteria,  which  are  constantly  and  naturally  present  on  any  sur- 
face which  is  exposed  to  the  air.  There  is  no  specific  micro- 
organism of  acute  or  chronic  rhinitis.  Generally  the  common 
pus-producing  cocci,  such  as  the  staphylococcus  citreus,  aureus, 
or  albus,  as  well  as  the  streptococci,  are  present.  Some  observ- 
ers have  also  pointed  out  the  presence  of  other  germs  under  cer- 
tain conditions,  looking  upon  them  as  etiologic  factors  in  the 
production  of  acute  rhinitis.  These  micro-organisms  are  the 
bacillus  lanceolatus  of  Friedlander,  the  bacillus  capsulatus  of 
Pfeiffer,  and  the  pneumococcus. 

The  general  treatment  in  the  early  stage  should  be  directed  to 
equalizing  the  circulation  by  cardiac  and  nerve  sedatives,  laxa- 
tives, etc.  Atropin  in  small  and  frequent  doses — nnnr  to  TUT 
of  a  grain  every  hour  or  two — has  a  controlling  effect  on  the 
vascular  dilatation  in  the  early  stage.  Locally,  such  sedatives  as 
the  vapor  of  menthol  and  camphor,  produced  by  placing  a  few 
grains  of  each  in  hot  water  and  allowing  the  child  to  inhale  the 
steam  as  it  arises,  or  menthol  in  olive  oil  or  liquid  petroleum, 
from  two  to  five  grains  to  the  ounce,  dropped  into  the  nose,  are 


CHRONIC    RHINITIS.  427 

of  service.  Simple  ointments  applied  to  the  nostrils  also  help 
to  relieve  irritation.  In  the  case  of  infants,  if  the  swelling  inter- 
feres with  suckling,  a  few  drops  of  a  I  or  2  per  cent,  solution  of 
cocain  may  be  used  in  the  nose  before  nursing.  In  the  later 
stage  a  spray  or  wash  should  be  applied  to  free  the  nose  from  the 
thick  secretions.  Such  a  wash  should  be  alkaline,  in  order  to 
dissolve  the  mucus,  and  of  about  the  specific  gravity  of  the  serum 
of  the  blood,  that  it  may  be  unirritating.  A  greater  or  less 
density  favors  osmosis  and  produces  irritation.  Dobell's  solution 
— sodium  bicarbonate  and  sodium  biborate,  of  each,  four  grains  ; 
carbolic  acid,  one  grain,  and  glycerin  three  fluidrams,  to  the 
ounce  of  boiled  water — is  an  excellent  solution  and  answers  the 
purpose.  Other  solutions,  however,  in  which  the  carbolic  acid 
is  replaced  by  vegetable  antiseptics,  such  as  menthol,  thymol, 
gaultheria,  eucalyptus,  etc.,  may  be  employed  instead.  They  may 
be  applied  by  an  atomizer,  or,  what  answers  the  purpose  better 
for  young  children,  a  small  soft-rubber  ball  syringe. 


CHRONIC  RHINITIS  (SIMPLE  AND  HYPERTROPHIC). 

These  are  but  stages  of  the  same  affection,  the  simple  passing 
into  the  hypertrophic.  Both  are  characterized  by  more  or  less 
nasal  obstruction — in  the  former,  temporary  swelling  or  turges- 
cence  of  the  turbinals,  shifting  from  one  side  to  the  other  ;  in  the 
latter,  permanent  engorgement,  due  to  hypertrophy  of  the  tur- 
binate  bodies.  In  both  the  secretions  are  apt  to  be  thick  and 
abundant.  The  cause  may  be  repeated  acute  attacks  or  some 
permanent  irritation  within  the  nose,  such  as  spurs  or  deviation 
of  the  septum.  The  indications  for  treatment  are  removal  of  the 
secretions  and  the  reduction  of  the  swelling  and  obstruction.  All 
projections  or  irregularities  of  the  septum  should  be  corrected,  and 
any  postnasal  or  faucial  obstruction  to  nasal  respiration  and  drain- 
age removed.  In  the  stage  before  the  hypertrophy  has  taken  place 
an  attempt  to  reduce  the  swelling  by  local  applications  (such  as 
the  following  :  lodin,  3  grains  ;  potassium  iodid,  6  grains  ;  gly- 
cerin and  water,  each,  y&  ounce  ;  or  menthol,  3  to  10  grains  in 
an  ounce  of  liquid  albolin  or  vaselin)  may  be  made.  If  this  fails, 
the  turbinates  should  be  cauterized,  preferably  by  one  of  the 
chemic  caustics,  such  as  chromic  acid  or  trichloracetic  acid.  In 
the  hypertrophic  stage  cauterization  by  the  galvanocautery  or 
removal  by  the  snare  may  be  required.  In  both  conditions  al- 
kaline antiseptic  washes  should  be  employed  and  the  passages 
kept  entirely  clean. 


428  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

PURULENT  RHINITIS. 

This  is  distinctively  a  disease  of  childhood.  It  may  be  the  result 
of  direct  infection  or  the  sequel  of  one  of  the  exanthemata. 
The  symptom  is  a  purulent  or  mucopurulent  discharge  from 
both  nostrils,  which  tends  to  collect  in  scabs  around  the  nostrils 
and  may  become  offensive.  The  treatment  consists  in  cleansing 
washes,  followed  by  some  mild  astringent,  such  as  glycerite  of 
tannin,  half  a  dram  to  the  ounce  of  water,  zinc  sulphocarbolate, 
five  grains  to  the  ounce  of  water,  or  alumnol,  five  to  ten  grains 
to  the  ounce  ;  and,  internally,  iron  and  cod-liver  oil. 

ATROPHIC  RHINITIS. 
Synonym. — OZENA. 

It  is  thought  by  some  that  atrophic  rhinitis  is  a  sequel  of 
purulent  rhinitis  ;  by  others  it  is  ascribed  to  scrofula  or  inherited 
syphilis.  It  is,  however,  a  distinct  affection  and  never  the  result 
of  the  hypertrophic  variety.  Its  chief  characteristics  are  the 
formation  of  crusts  throughout  the  nasal  cavities,  generally 
extremely  fetid,  and  increased  size  of  the  cavities  from  wast- 
ing of  the  turbinates  and  membrane.  The  indications  for  treat- 
ment are  cleansing,  stimulation,  and  protection.  The  crusts 
must  be  thoroughly  removed  by  spray,  syringe,  or  cotton  swab. 
Any  of  the  alkaline  solutions  above  mentioned  may  be  used,  but 
their  antiseptic  properties  should  be  increased.  Thymol,  which 
is  a  good  antiseptic  and  deodorizer  in  this  condition,  may  be 
added  to  any  of  the  cleansing  washes,  in  the  proportion  of  j^ 
or  y2  of  a  grain  to  the  ounce.  After  all  the  crusts  have  been 
removed  some  stimulating  application  should  be  made.  Nitrate 
of  silver,  five  to  ten  grains  to  the  fluidounce,  or  a  solution  of 
thymol,  ten  grains  to  the  ounce,  has  been  found  efficient ;  after 
this  an  oily  substance,  preferably  vaselin,  either  plain  or  medi- 
cated, warmed  and  sprayed  into  the  nose,  to  protect  the  surface 
from  rapid  drying.  Such  treatment  must  be  carried  out  by  the 
physician  at  least  three  times  a  week  at  first.  In  the  intervals 
the  patient  can  use  the  cleansing  wash  as  a  spray  or  douche  at 
home  in  the  morning  and  evening,  following  it  with  one  of  the 
liquid  petroleum  preparations,  with  oil  of  eucalyptus  or  menthol 
added.  The  treatment  must  be  kept  up  continuously  until  the 
crusts  cease  to  form  in  the  nose,  or,  at  least,  until  the  patient  is 
able  to  keep  the  nose  free  from  crusts.  The  patient,  however, 
must  continue  to  use  some  cleansing  wash  for  a  long  time  after- 
ward. 


SYPHILITIC    RHINITIS.  429 

CROUPOUS  OR  MEMBRANOUS  RHINITIS. 

This  is  not  an  uncommon  affection  in  children.  It  is  char- 
acterized by  the  formation  of  a  false  membrane  in  the  nose,  which 
can  be  readily  detached  but  rapidly  reforms.  Constitutional 
disturbance  is  very  slight.  The  principal  symptom  is  nasal 
stenosis.  Bacteriologic  cultures  have  shown  streptococcus  and, 
in  some  cases,  the  diphtheria  bacillus.  Clinically,  the  two  forms 
are  identical.  The  duration  of  the  disease  is  from  two  to  three 
weeks.  The  treatment  consists  in  the  removal  of  any  loose 
membrane,  cleansing,  and  the  insufflation  of  iodoform  (europhen 
or  nosophen  if  preferred)  or  calomel.  Dilute  lime-water  has 
been  suggested  by  McBride.  Iron  and  bichlorid  of  mercury  or 
calomel  in  small  doses  should  be  given  internally. 

SYPHILITIC  RHINITIS. 

The  coryza  of  syphilis  is  more  frequently  noted  in  infants  than 
in  adults.  Any  obstinate  nasal  catarrh  in  an  infant  should  sug- 
gest the  possibility  of  syphilis.  The  children  usually  appear 
emaciated,  and  skin  eruptions  will  generally  be  found.  There 
are  swelling  of  the  membrane  and  hypersecretion,  which  may  be 
purulent  and  bloody.  In  tertiary  syphilis,  which  rarely  appears 
before  the  fifth  year,  infiltrations  of  gummatous  material,  ulcera- 
tions, — especially  of  the  septum, — and  necrosis  of  bone  may  be 
found.  In  syphilis  of  the  nose  the  treatment  is  very  important. 
In  infants  the  stenosis  often  prevents  suckling,  necessitating 
feeding  by  the  spoon.  Tonics  are  indicated,  such  as  syrup  of 
the  iodid  of  iron  and  cod-liver  oil.  In  the  secondary  stage  mer- 
curials are  all-important.  They  can  be  given  by  the  mouth  or 
by  inunction.  The  nose  must  be  kept  clear  by  antiseptic  washes. 
Menthol  in  oil  (5  to  10  grains  to  i  fluidounce)  may  be  used  to 
relieve  the  stenosis.  In  the  tertiary  stage  destruction  of  tissue 
is  rapid,  and  the  resulting  deformity  may  be  very  great.  Iodid 
of  potassium  should  be  given  in  increasing  doses  up  to  the  limit 
of  tolerance.  Mercurials  are  of  no  use  in  tertiary  syphilis  of  the 
nose.  Seiler  recommends  the  surgical  removal  of  the  infiltrated 
tissues  to  prevent  destructive  ulceration.  Iodoform  should  be 
used  locally. 

MUCOUS  POLYPI  (EDEMATOUS  FIBROMATA). 

These  do  not  occur  in  infants,  but  are  not  infrequent  in  older 
children.  They  grow  from  the  upper  portion  of  the  nasal  cav- 
ity, but  by  elongation  of  the  pedicle  may  occupy  any  portion  of 


43O  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

the  nares  and  extend  into  the  nasopharynx.  They  produce  nasal 
stenosis  and  watery  discharge,  greater  in  damp  weather.  They 
do  not,  as  a  rule,  cause  deformity.  Headache,  laryngeal  spasm, 
and  asthma  are  often  due  to  their  presence.  Polypi  may  be 
caused  by  disease  of  the  accessory  sinuses  or  by  any  prolonged 
irritation  of  the  nasal  cavities.  The  growths  should  be  thor- 
oughly removed  and  any  underlying  disease  treated. 

FIBROUS  TUMORS. 

Nasal  fibromata  appear  as  dense  white  or  reddish  tumors. 
They  spring  from  the  periosteum  or  bone.  Their  favorite  loca- 
tion is  at  the  vault  of  the  pharynx,  whence  they  advance  into  the 
nasal  cavities,  by  their  growth  spreading  the  bones  apart  and 
often  producing  great  deformity  (frog-face).  They  should  be 
attacked  early.  Electrolysis  has  been  successful  in  some  cases. 

ADENOID  VEGETATION. 

There  is  normally  at  the  vault  of  the  pharynx  a  group  of 
lymphoid  glands  called  the  pharyngeal  tonsil.  Hypertrophy  of 
this  tissue  is  known  as  adenoid  vegetation  or  hypertrophy  of  the 
pharyngeal  tonsil.  This  condition  is  most  frequently  found  in 
childhood,  as  the  lymphoid  tissue  here,  as  well  as  that  in  the 
fauces,  tends  to  atrophy  in  later  life.  It  is  one  of  the  most  com- 
mon causes  of  mouth-breathing  in  children,  and  a  frequent 
source  of  nasal  and  postnasal  discharge,  cough,  laryngeal  spasm, 
asthma,  etc.  Deafness  and  suppuration  of  the  middle  ear  may 
also  be  due  to  these  growths.  Headache,  frontal  or  occipital,  is 
often  complained  of  by  children  afflicted  with  adenoids.  Aden- 
oids may  be  congenital,  but  are  generally  of  later  growth,  fre- 
quently appearing  after  measles,  scarlatina,  diphtheria,  or  whoop- 
ing-cough. A  hereditary  predisposition  probably  exists,  as  they 
are  often  found  in  several  members  of  the  same  family.  They 
are  often  associated  with  hypertrophy  of  the  faucial  tonsils  and 
the  pharyngeal  follicles.  A  diagnosis  can  sometimes  be  made  by 
the  rhinoscopic  mirror,  but  in  young  children  digital  examination 
is  more  satisfactory.  In  all  cases  where  the  growth  is  sufficient 
to  cause  symptoms  it  should  be  removed.  Local  applications 
have  no  effect  on  these  hypertrophies. 

ACUTE  PHARYNGITIS. 

This  is  usually  caused  by  exposure  to  cold  or  dampness,  espe- 
cially in  those  already  debilitated  by  hereditary  influences  or  by 


RETROPHARYNGEAL    ABSCESS.  43  I 

living  in  a  vitiated  atmosphere.  There  is  often  a  disturbed  con- 
dition of  the  digestion  along  with  this  or  acting  as  a  cause.  The 
attack  is  accompanied  by  fever,  headache,  pain  in  the  throat, 
coated  tongue,  and  constipation.  Examination  of  the  fauces 
may  show  a  general  redness  or  only  streaks  of  congestion  on 
the  lateral  walls  of  the  pharynx  and  the  half-arches.  Hot  foot- 
baths, aconite  in  small  and  frequent  doses,  laxatives,  etc.,  con- 
stitute the  general  treatment.  Locally,  mild  astringents,  such  as 
glycerite  of  tannin,  diluted,  or  a  single  application  of  silver  nitrate, 
sixty  grains  to  the  ounce,  followed  by  mild  astringent  gargles, 
are  commonly  employed.  Wet  compresses  to  the  neck  are  use- 
ful and  give  comfort. 

RHEUMATIC  PHARYNGITIS. 

This  is  characterized  by  but  slight  congestion  of  the  mem- 
brane, but  a  disproportionately  severe  pain  in  deglutition.  It 
usually  occurs  in  rheumatic  subjects  and  is  not  frequent  in  child- 
hood. Antirheumatic  remedies  should  be  given.  Heat  to  the 
neck  and  rubbing  with  stimulating  liniments  give  relief. 

RETROPHARYNGEAL  ABSCESS   (RETROPHARYN- 
GEAL  LYMPHADENITIS). 

The  lymphatic  glands  embedded  in  the  posterior  wall  of  the 
pharynx  occasionally  suppurate,  forming  an  abscess  most  dan- 
gerous to  life  because  of  mechanical  obstruction  to  the  trachea, 
produced  by  pressure  or  edema,  or  by  suffocation  from  a  sponta- 
neous opening  deluging  the  air-passages  with  pus.  It  is  of  much 
importance  to  recognize  the  condition  promptly,  both  to  institute 
treatment,  if  time  permits,  or  to  meet  the  exigencies  thus  induced, 
and,  above  all,  to  differentiate  this  from  simple  tonsillitis,  laryngeal 
stenosis,  or  impaction  of  a  foreign  body.  Two  varieties  exist, 
one,  the  commoner,  occurring  in  infants  usually  under  one  or 
two  years,  seldom  above  three ;  the  other,  rarer,  resulting  from 
caries  of  the  cervical  vertebrae,  is  seen  only  in  older  children. 

The  retropharyngeal  lymph-nodes  are  described  (Simon)  as 
forming  a  chain  on  each  side  of  the  median  line  between  the 
pharyngeal  and  prevertebral  muscles  ;  these  undergo  atrophy 
after  the  third  year.  The  adenitis  may  be  severe  enough  to  pro- 
duce serious  local  symptoms,  yet  stop  short  of  suppuration  ;  it  is 
also  occasionally  associated  with  external  cervico-adenitis. 

Causes. — Children  are  very  prone  to  lymphatic  inflammations, 
especially  of  the  cervical  glands.  The  causes  of  retropharyngeal 


432  DISEASES    OF    THE    RESPIRATORY    ORGAN'S. 

abscess  are  usually  specific  infections,  most  often  tubercular  or 
influenzal  or  less  frequently  following  scarlatina,  measles,  or 
diphtheria.  The  immediate  cause  is  usually  an  inflammatory 
condition  of  the  nasal  or  pharyngeal  mucous  membrane.  Abscess 
sometimes  occurs  in  children  hitherto  vigorous,  but  more  readily 
in  the  weaker  ones,  subject  to  catarrhal  affections. 

Symptoms. — Abscess  of  the  retropharynx  may  begin  slowly 
or  arise  with  alarming  suddenness  ;  indeed,  sometimes  death  is 
imminent  or  occurs  before  the  trouble  is,  or  can  be.  suspected. 
The  situation  is  in  sight  on  the  vault  of  the  pharynx,  or  low 
down,  where  it  can  only  be  felt  by  the  finger.  The  swelling  may 
be  seen  nearly  in  the  median  wall  of  the  pharynx  or  oftenerto  one 
side.  There  may  have  been  an  antecedent  catarrh.  There  may 
be  high  temperature,  loss  of  flesh,  and  other  evidences  of  an 
acute  suppurative  process — a  prostration  out  of  all  proportion  to 
the  other  phenomena.  The  first  definite  symptom  is  usually  an 
attack  of  dyspnea  or  asphyxia,  due  to  pressure  of  the  abscess  on 
the  larynx.  Labored  mouth-breathing  during  sleep  is  usual,  the 
head  is  thrown  back,  and  there  is  difficulty  in  swallowing.  The 
voice  becomes  nasal,  food  is  regurgitated  through  the  nose  or 
mouth,  and  a  squeaking  cry  occurs,  resembling  the  "quacking" 
of  a  duck.  The  tumor  sometimes  shows  externally.  The  finger 
in  the  throat  will  tell  most  by  demonstrating  the  position,  size, 
and  consistency  of  the  mass. 

Prognosis. — Death  may  result  by  suffocation,  asphyxia,  or 
drowning  by  pus  when  the  disease  is  not  recognized  early 
enough,  and  rarely  may  come  from  burrowing,  ulceration  of  the 
carotid,  etc.  If  the  prostration  is  profound,  this  may  cause 
death  after  the  pus  is  evacuated.  The  mortality  is  5  per  cent 

Diagnosis. — Instances  of  trouble  in  swallowing  occurring 
among  infants  with  mouth-breathing  or  dyspnea  call  for  exami- 
nation of  the  throat  by  touch  as  well  as  inspection  ;  not  many 
mistakes  will  then  be  made.  Few  accomplishments  in  examin- 
ing children  are  more  important  than  to  acquire  skill  in  touch- 
ing the  throat  with  an  exploring  finger  for  this  or  other  morbid 
conditions. 

Treatment. — If  the  condition  is  recognized  early  enough, 
relief  can  be  obtained  by  hot  applications,  chiefly  to  assist  the 
abscess  in  pointing  ;  resolution  can  scarcely  be  hoped  for.  When 
pus  is  evident,  the  cavity  should  be  opened  at  once,  using  great 
care  to  prevent  the  pus  from  flowing  into  the  trachea,  which  is 
best  accomplished  by  keeping  the  head  well  forward  or  it  may 
be  thrown  forward  the  instant  pus  is  set  free.  It  is  not  well 
to  use  a  gag  ;  but  this  alone  may  cause  serious  asphyxia.  It 


TONSILLITIS.  433 

is  also  recommended  that  the  instrument  to  make  the  opening 
should  be  the  human  finger-nail  in  preference  to  a  knife.  We 
have  used  this  on  two  occasions  and  seen  it  done  by  others  with 
good  effect.  A  knife  is  sometimes  required,  when  the  mouth 
should  be  opened  and  held  in  position  with  a  small,  narrow 
tongue-depressor  (our  device  of  a  wire  loop  serves  us  best),  and 
the  incisions  made  with  a  short-bladed  tenotome,  from  the  side 
toward  the  median  line.  We  can  not  see  the  force  of  the  claims 
of  certain  surgeons  who  insist  on  the  advantages  of  external  in- 
cision, except  it  may  be  for  the  cases  due  to  Pott's  disease.  If  the 
abscess  is  large  and  the  tissue  at  the  side  of  the  pharynx  is  in- 
volved, and  especially  if  there  is  burrowing  of  pus  into  the  deeper 
tissue,  then,  in  order  to  insure  proper  drainage,  an  incision  should 
be  made  in  the  neck  and  the  wound  and  abscess  cavity  packed 
with  gauze. 

RETROPHARYNGEAL   ABSCESS    FROM    CARIES    OF   THE    CERVICAL 

VERTEBRA. 

This  variety  is  rare,  and  seldom  occurs  in  children  under  three 
years  of  age.  The  pus-cavity  is  larger,  forms  slowly,  often  for 
months,  and  is  accompanied  by  more  marked  constitutional 
depression  but  less  sudden  changes  ;  the  swelling  is  oftener  in 
the  median  line,  and  not  so  circumscribed.  The  symptoms  of 
cervical  Pott's  disease  usually  precede,  though  the  abscess  may 
occur  before  the  deformity,  and  external  swelling  is  more  com- 
mon ;  on  digital  exploration  an  angular  prominence  may  be  felt 
on  the  posterior  wall  of  the  pharynx.  This  form  of  abscess 
may  open  spontaneously  on  the  outer  surface  below  the  jaw,  or 
lower  in  the  neck,  or  the  pus  burrows  in  front  of  the  spine ;  the 
cavity,  once  open  by  punctures  or  spontaneously,  may  refill  and 
become  a  slowly  discharging  sinus.  The  treatment  is  incision, 
preferably  external,  and  drainage.  We  saw  a  case  of  a  boy, 
eight  years  of  age,  in  a  hospital  become  asphyxiated  during 
dinner,  and  on  thrusting  the  finger  in  the  throat  to  extract  a 
piece  of  food  suspected  of  causing  this,  buried  our  finger  in  a 
large  cavity,  and  a  fragment  of  meat  was  withdrawn,  along  with 
several  ounces  of  pus.  Once  opened,  the  cavity  heals,  as  a  rule, 
but  it  sometimes  requires  cleaning  out  and  scraping. 

TONSILLITIS. 
Synonym. — AMYGDALITIS. 

Tonsillitis  is  either  acute  or  chronic.  The  acute  conditions  are 
divided  into  three  varieties — the  superficial,  or  catarrhal,  which 

28 


434  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

does  not  differ  materially  from  simple  pharyngitis  ;  the  follicular 
or  lacunar  ;  and  the  phlegmonous,  or  quinsy. 

Causes. — Acute  tonsillitis  is  very  common  among  children 
and  is  liable  to  occur  at  any  age.  The  fact  that  epidemics  of  it 
occur  at  times  points  clearly  to  the  bacteriologic  origin  of  the 
disease.  Certain  germs  have  been  isolated  in  the  anginas,  many 
of  which  are  found  normally  in  the  mouth,  and  in  the  order  of 
their  frequency  may  be  mentioned  :  the  pneumococcus,  diphtheria 
bacillus,  streptococcus  pyogenes,  diplococcus  scarlatinae,  influenza 
bacillus,  staphylococcus  pyogenes,  and  the  tubercle  bacillus.  In 
making  the  cultures  not  infrequently  is  found  and  isolated  a  mixed 
infection  of  two  or  more  of  these. 

A  rheumatic  diathesis  exerts  a  marked  influence  over  the  an- 
ginas as  a  predisposing  cause.  Exposures  to  wet  and  cold,  as 
to  poor  ventilation  and  unhygienic  surroundings,  act  as  exciting 
causes,  debilitating  the  system,  and  especially  the  tissues  of  the 
throat,  for  the  reception  of  the  infections.  Overexertion  of  the 
voice  also  prepares  the  soil  for  these  germs. 

Symptoms. — The  symptomatology  of  tonsillitis  is  the  same 
for  the  three  varieties,  varying  in  severity  with  the  condition  ;  thus 
we  have  pain  in  the  throat,  with  difficult  swallowing  and  articu- 
lation, the  voice  sounding  as  though  the  mouth  were  filled  with 
some  soft  food.  There  is  marked  tenderness  at  the  angle  of  the 
jaw  on  pressure,  and  usually  a  swelling  is  apparent.  Fever  always 
accompanies  to  a  greater  or  less  degree,  reaching  as  high  as 
104°  to  105°  F.  (40°  to  40.6°  C.)  in  the  severer  forms,  often  fol- 
lowed by  a  decided  chill. 

In  the  simple  form  the  tonsils  are  uniformly  enlarged,  injected, 
and  bathed  in  thick,  tenacious  mucus. 

In  the  lacunar  form  the  tonsils  are  not  always  so  uniformly 
enlarged,  but  one  or  both  are  markedly  swollen,  and  dotted 
throughout  the  surface  with  yellow  or  whitish  spots  of  various 
sizes  ;  these  spots  are  where  the  lacunae  or  crypts  are  filled  with 
debris  from  degenerated  cells,  caused  by  the  bacterial  inva- 
sion, and  swollen  from  the  occlusion  of  their  outlets.  These 
lacunae  or  crypts  discharge  their  contents  in  the  latter  stages  of 
the  disease,  causing  an  offensive  odor.  The  exudate  from  the 
crypts  may  extend  in  the  severe  types  to  the  whole  surface  of  the 
gland,  rarely  beyond,  simulating  diphtheria,  a  difference  in  the 
color  being,  however,  apparent,  the  former  being  of  a  bluish  or 
yellowish,  creamy  tinge,  while  the  latter  is  more  grayish. 

In  the  phlegmonous  form  of  tonsillitis,  commonly  known  as 
quinsy,  a  more  marked  and  general  constitutional  disturbance  is 
noted,  the  tonsils  are  greatly  swollen,  and  the  pain  becomes 


TONSILLITIS.  435 

intense  and  throbbing.  There  is  here  an  invasion  into  the  body 
of  the  gland,  tending  to  form  an  abscess.  One  gland  only,  as 
a  rule,  is  severely  affected  ;  this  enlarges  rapidly,  pushing  toward 
the  surface,  in  the  line  of  least  resistance,  softening,  fluctuating, 
and  finally  suppurating  and  bursting  on  the  surface.  The  sur- 
rounding tissues  soon  become  involved,  and  the  glands  of  the 
neck  are  engorged,  which  no  doubt  gives  rise  to  the  term  of 
peritonsillitis.  The  swallowing  becomes  almost  impossible, 
fluids  being  regurgitated  through  the  nose  ;  the  breathing  is 
difficult  and  the  speech  much  restricted ;  the  fever  runs  as  high 
as  105°  F.  (40.6°  C.),  being  irregular  in  its  intermittence,  as  in 
all  forms  of  pus  infections.  The  pulse  may  be  as  high  as  130, 
and  there  is  often  marked  salivation,  earache,  and  even  delirium. 
Headaches  and  backaches  are  common,  and  albuminuria  is  not 
rare. 

Quinsy  occurs  more  frequently  when  there  are  great  climatic 
changes,  usually  during  the  cold  and  damp  seasons.  It  rarely 
troubles  very  young  children. 

In  children  tonsillitis  may  be  mistaken  for  the  acute  pharyn- 
geal  inflammation  of  scarlet  fever,  especially  when  in  tonsillitis 
there  is  an  accidental  rash.  Tonsillitis  may,  however,  be  distin- 
guished from  scarlet  fever  by  a  history  of  contagion,  with  an 
onset  of  vomiting,  a  strawberry  tongue,  the  characteristic  pulse, 
and,  finally,  the  peculiar  rash  of  scarlet  fever.  Diphtheria  is 
claimed  by  some  to  be  distinguished  from  follicular  tonsillitis  by 
the  appearance  of  the  false  membrane,  which  extends  to  the  sur- 
rounding parts,  and  is  of  a  grayish,  creamy  tinge,  curled  at  its 
edges,  and,  when  removed,  leaves  a  raw  surface  ;  also  there  may 
be  a  history  of  contagion  and  a  rapid  weak  pulse,  with  marked 
swelling  of  the  submaxillary  gland. 

No  one  may  trust  such  a  differentiation,  but,  when  possible, 
should  always  proceed  to  make  a  bacteriologic  examination  and 
isolate  the  patient  until  the  report  comes  back  from  the  laboratory. 

Prognosis. — The  prognosis  of  tonsillitis  is  generally  favorable, 
even  in  the  severer  cases,  and  when  the  patient  is  in  the  gravest 
condition  the  abscess  frequently  ruptures  spontaneously,  giving 
immediate  relief.  It  is  only  when  ulceration  takes  place  through 
the  carotid  or  the  abscess  bursts  during  sleep,  causing  suffoca- 
tion, that  we  hear  of  fatal  results.  The  duration  of  the  disease 
is  from  two  days  to  two  weeks. 

Treatment. — The  treatment  consists  of  rest,  quiet,  and  avoid- 
ance of  exposure  ;  the  best  external  application  is  ice  or  cold 
cloths  applied  at  least  every  hour  or  two.  For  pain,  dry  heat  or 
poultices  often  give  relief.  Free  purging  with  calomel  or  salines 


436  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

is  of  great  value.  In  the  simple  form  swabbing  the  throat  with  sul- 
phate of  zinc  solution,  twenty  grains  to  one  fluidounce,  or  tincture 
of  red  gum  is  of  use.  For  older  children  gargling  with  extremely 
hot  water  for  some  ten  or  fifteen  minutes,  followed  by  gargles 
of  astringents,  such  as  potassium  chlorate,  two  drams,  or  rhus 
glabra,  one  ounce,  to  a  pint  of  hot  water  is  very  comforting  and 
effective.  The  follicular  form  should  be  treated  with  similar 
gargles  and  astringents  after  thoroughly  disinfecting  the  parts  by 
a  spray  of  a  solution  of  hydrogen  peroxid  or  a  direct  application 
of  the  same  on  a  pledget  of  cotton  into  the  crypts  of  the  tonsils. 
Internally  sodium  salicylate,  two  to  five  grains  thrice  daily,  may 
at  times  shorten  the  attack  and  relieve  the  pain.  Calomel,  -£$ 
of  a  grain  directly  on  the  tongue,  repeated  half  hourly,  is  often 
useful.  The  phlegmonous  form,  in  addition  to  the  above,  usually 
needs  surgical  interference.  Whenever  pus  is  suspected  or 
fluctuation  felt,  a  free  incision  is  instantly  demanded.  This  is 
best  done  on  the  soft  palate  outside  the  line  of  the  anterior  pillar, 
by  means  of  a  guarded  bistoury,  which  should  be  wrapped  within 
half  an  inch  of  the  point.  Should  pus  not  be  found,  a  probe 
can  be  passed  deeper  with  safety.  Great  relief  immediately 
follows  the  evacuation  of  the  pus-cavity,  and  the  inflammation 
rapidly  subsides. 

Sequelae. — The  sequelae  of  tonsillitis  have  only  recently,  been 
recognized  to  be  of  much  gravity.  In  the  last  few  years  many  in- 
vestigators have  made  careful  studies  of  this  subject,  and  it  is  a 
well-established  fact  that  the  tonsils  are  an  open  gateway  for  the 
reception  of  many  kinds  of  germs,  and  are  as  great  a  source  of 
infection  as  the  Peyer's  patches  or  Brunner's  glands. 

Jessen,  Buschke,  Boeck,  Buss,  Hodenpyl,  Ribbert,  Du  Mes- 
nil,  De  Rochemont,  Packard,  Mayer,  and  Ohr  have  reported 
cases  of  grave  conditions  following  attacks  of  tonsillitis.  Thus 
it  has  been  found  that  attacks  of  albuminuria,  erythema,  urticaria, 
purpura,  erysipelas,  orchitis,  oophoritis,  pleuropneumonia,  stra- 
bismus, and  paraplegia  have  been  traced  directly  to  tonsillar  inva- 
sion. Angina  pectoris,  phlebitis,  purulent  pleurisy,  and  even 
tuberculosis  have  followed  these  attacks.  Endocarditis  is  by  no 
means  an  uncommon  sequela,  and  general  pyemia  has  been 
reported  as  consequent  upon  this  apparently  simple  disease. 

Otitis  media,  with  its  mastoid  and  intercranial  complications, 
has  frequently  been  traced  to  attacks  of  tonsillar  inflammation  ; 
especially  is  this  true  following  the  throat  troubles  of  scarlatina. 
Nor  does  the  severity  of  the  attack  bear  definite  reference  to  the 
gravity  of  the  sequelae,  which  oftentimes  appear  late  and  after 
all  the  throat  symptoms  have  cleared  up. 


CHRONIC    TONSILLITIS DISORDERS    OF    SPEECH.  437 

CHRONIC  TONSILLITIS  (HYPERTROPHY  OF 
THE  TONSILS). 

Chronic  enlargement  of  the  faucial  tonsils  may  be  found  in 
infancy  and  early  childhood,  but  it  is  much  more  frequent  in  later 
childhood.  When  present  in  early  life,  the  cause  is  probably 
heredity.  Later  the  enlargement  may  be  due  to  previous  attacks 
of  acute  inflammation  or  to  bad  hygienic  surroundings,  constitu- 
tional disease,  etc.  Bosworth  describes  two  varieties  of  enlarge- 
ment of  the  tonsils — the  hypertrophic  and  the  hyperplastic.  In 
the  former  the  glandular  tissue  is  mainly  increased,  and  the  tonsil 
is  rough  and  irregular  in  appearance.  Jh  the  latter  the  fibrous 
tissue  is  increased,  the  tonsil  presenting  a  smooth  and  round 
appearance.  Very  often  tonsils  exhibit  a  combination  of  these 
conditions.  Tonsils  in  which  the  crypts  are  chronically  diseased 
and  have  become  the  seat  of  cheesy  deposits  may  be  only  slightly 
or  not  at  all  enlarged,  but  are  a  source  of  irritation  and  are 
subject  to  attacks  of  acute  inflammation.  Many  symptoms  are 
ascribed  to  hypertrophy  of  the  tonsils,  most  of  which  are  due  to 
the  obstruction  to  respiration,  nasal  and  oral,  caused  by  their 
presence.  The  chief  symptoms  are  a  snoring  during  sleep,  rest- 
lessness, thick  or  nasal  voice,  liability  to  take  cold,  deafness,  and 
tinnitus.  Internal  remedies  have  very  little  effect  on  tonsillar 
hypertrophy.  Tonics,  etc.,  should  be  given  for  the  general  con- 
dition, which  is  apt  to  suffer  in  these  cases.  As  local  applica- 
tions, the  compound  tincture  of  iodin,  diluted  ;  tincture  of  the 
chlorid  of  iron  (one  part  to  three  of  glycerin) ;  glycerite  of  tannin, 
and  nitrate  of  silver  (ten  to  twenty  grains  to  the  ounce)  are  used. 
Of  these  the  iodin  and  the  iron  solutions  are  of  the  most  value. 
They  can  be  used  in  recent,  soft  hypertrophies.  If  the  crypts 
are  diseased,  they  should  be  cauterized  with  chromic  acid,  fused 
on  a  probe,  or  the  galvanocautery  point  carried  into  the  crypts. 
In  moderate  degrees  of  hypertrophy,  also,  the  galvanopuncture 
may  produce  shrinking  and  atrophy.  When  the  tonsil  is  large 
and  firm,  however,  excision  is  the  only  treatment  to  be  advised. 

DISORDERS  OF  SPEECH. 

CHIEFLY  THOSE  DUE  TO  ANATOMIC  DEFECTS  OF  THE  SPEECH 
APPARATUS. 

The  importance  of  clear  speech  as  a  factor  in  mental  and  physi- 
cal development  is  scarcely  appreciated,  and  the  subject  fails  to 
receive  the  attention  it  deserves.  Defective  speech  is  not  always 
the  result  of  defective  mentality,  as  many  seem  to  think,  but  it  is 


438  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

quite  as  often  the  cause.  The  child  can  not  speak  because  it  is 
thought  to  be  stupid,  whereas  the  child  is  often  dull  because  it 
can  not  speak. 

The  speech  faculty  develops  not  by  intuition,  but  by  imitation, 
and  there  are  two  ways  in  which  this  development  may  be 
retarded  :  first,  the  child's  imitative  capacity  may  be  weak,  while 
all  the  other  faculties  are  strong,  and  then  speech,  which  is  so 
largely  dependent  upon  the  imitative  faculty,  will  necessarily 
develop  slowly  and  imperfectly.  Again,  the  child  may  have  had 
poor  models  of  speech  in  those  having  it  in  charge,  and  the 
result  is  equally  unfortunate.  This  explains  why  these  defects 
are  so  common  among  the  poorer  classes,  where  the  imitative 
faculty  is  oftentimes  but  little  developed  and  where  the  speech  of 
the  attendants  is  careless  and  slovenly. 

Defective  hearing  is  also  an  obstruction  to  the  normal  develop- 
ment of  speech  in  children.  Total  deafness,  either  before  or 
during  the  formative  speech  period,  always  results  in  faulty 
speech,  because  the  child  can  not  imitate  what  it  does  not  ac- 
curately hear  ;  but  in  addition  to  this  often  those  "  having  ears, 
hear  not."  We  have  those  who  possess  no  ear  for  speech,  just 
as  there  are  those  who  have  no  "  ear  for  music."  They  hear  the 
speech  as  they  hear  the  music,  but  the  ear  and  brain  do  not 
make  the  fine  distinctions  so  necessary  for  its  sensitive  differentia- 
tion or  normal  development ;  and  so,  just  as  the  training  of  the 
ear  forms  an  essential  part  in  the  training  of  the  musician,  and 
just  as  some  ears  require  more  training  for  music  than  others,  so 
the  training  of  the  ear  should  not  be  overlooked  in  those  chil- 
dren who  are  backward  in  the  development  of  speech.  They 
must  be  taught  to  hear  the  sounds  correctly  and  to  distinguish 
them,  the  one  from  the  other,  before  they  can  ever  learn  to  ex- 
ecute them. 

Various  other  subjective  physical  conditions  influence  the 
development  of  speech  in  children.  Indeed,  anything  which 
makes  speech  difficult  or  even  disagreeable  to  the  child  may  re- 
sult in  serious  imperfections.  Obstructions  in  the  nostrils  due  to 
hypertrophied  turbinals,  irregularities  of  the  septum,  or  adenoid 
vegetation  in  the  vault  of  the  pharynx  act  in  several  ways  to  im- 
pede speech  development.  They  interfere  with  normal  respiration 
and  with  the  resonance  of  the  voice  ;  they  set  up  a  catarrhal 
condition  of  the  vocal  organs,  and  oftentimes  press  upon  certain 
important  nerve  filaments,  causing  irregular  choreic  movements 
of  the  muscles  controlling  voice  and  speech. 

In  all  cases  of  delayed  or  arrested  speech  development  these 
parts  should  be  carefully  and  thoroughly  examined  and  put  in 


DISORDERS    OF    SPEECH.  439 

the  best  possible  condition.  Nasal  spurs  should  be  removed, 
deflected  septa  straightened,  and  hypertrophied  turbinals  reduced, 
always  bearing  in  mind  that  the  slightest  deviation  from  the 
normal  in  the  upper  respiratory  region  during  the  formative 
period  may  render  speech  difficult  and  disagreeable,  and  there- 
fore impossible,  to  the  child  who  does  not  appreciate  the  import- 
ance of  good  speech  sufficiently  to  make  an  effort  to  overcome 
even  slight  impediments. 

We  have  known  a  small  adenoid  growth  in  the  pharyngeal 
vault  to  cause  stuttering  of  the  severest  type,  and  the  defect  of 
speech  to  cease  immediately  upon  the  removal  of  the  growth. 
A  long  and  curled  epiglottis  setting  up  a  pharyngeal  and  laryn- 
geal  irritation  may  be  the  cause  of  the  disordered  speech,  and  we 
have  had  most  excellent  results,  in  at  least  one  case,  by  the 
removal  of  its  upper  border. 

Another  fruitful  source  of  defective  speech  is  found  in  hyper- 
trophied faucial  tonsils  which  press  upon  the  pillars  of  the  palate 
and  encroach  upon  the  oropharyngeal  resonant  space.  We 
often  see,  also,  inflammatory  adhesions  binding  the  tonsils  to 
the  pillars,  and  preventing  that  free  action  of  the  palatopharyn- 
geal  and  palatoglossal  muscles  which  is  so  essential  to  good 
articulation.  These  adhesions  should  be  destroyed,  preferably 
by  the  electric  cautery,  if  the  child  be  sufficiently  tractable,  and 
the  tonsil  should  be  reduced  in  size,  either  by  surgical  or  less 
drastic  measures. 

So  important  an  organ  is  the  tongue  that  its  very  name  has 
come  to  be  regarded  as  a  synonym  for  speech,  and  "  tongue-tie  " 
is  generally  supposed  to  be  the  chief  cause  of  defective  speech. 

By  tongue-tie  we  mean  a  short  frenum  interfering  with  the 
movements  of  the  tip  of  the  tongue.  This  we  do  find,  of  course, 
in  some  children,  and  the  snipping  of  this  frenum  undoubtedly 
gives  greater  freedom  to  the  tip ;  but  in  many  cases  the  trouble 
is  not  in  the  frenum  alone,  but  in  the  disposition  of  the  anterior 
fibers  of  the  geniohyoglossus  muscles.  These  fibers  are  too 
short,  and  they  are  inserted  into  the  body  of  the  tongue  too  far 
forward  toward  its  tip,  thus  preventing  some  of  the  most  im- 
portant movements  of  this  organ.  And  so  in  the  majority  of 
cases  the  snipping  of  the  frenum  is  not  enough  to  loosen  the 
tongue,  but  an  incision  must  be  made  through  the  mucous  mem- 
brane low  down  in  the  floor  of  the  mouth,  and  about  one-half  the 
width  of  the  tongue,  so  that  the  anterior  fibers  of  muscle  are 
divided  sufficiently  far  back  to  give  the  tongue  its  normal  amount 
of  free  surface  and  motion.  This  operation  is  described  and 
illustrated  by  G.  Hudson  Macuen  in  a  recent  number  of  the 


44O  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

journal,  "International  Clinics,"  and  is  one  which  is  more  fre- 
quently indicated  than  the  somewhat  simpler  method  of  snipping 
the  frenum.  In  cases  of  cleft  palate  the  operation  should  be  done 
in  the  first  year,  before  the  formative  speech  period  begins,  one 
of  the  chief  indications  in  this  operation  being  to  retain  as  much  as 
possible  of  the  soft  palate  and  uvula,  and  to  restore  to  them  their 
normal  functional  activity.  Generally  in  these  cases  there  is  too 
little  velum  palati  after  the  operation  and  too  little  activity  in  the 
muscles  which  control  it,  the  result  being  an  inability  to  close 
the  palatopharyngeal  chink  (the  opening  from  the  oropharynx 
into  the  nasopharynx),  and  the  stream  of  sounding  breath  which 
should  pass  out  through  the  mouth  during  speech  is  allowed  to 
escape  through  the  nostrils  ;  hence  all  the  consonant  sounds 
except  the  nasals  must  necessarily  be  defective. 

Much  may  be  done  after  the  cleft  palate  operation  to  remedy 
this  condition.  All  adhesions  between  the  pillars  should  be 
broken  up,  and  systematic  massage  of  the  palate,  such  as 
stretching  with  the  finger,  etc.,  should  be  practised. 

The  most  important  and  the  most  neglected  part  of  the  treat- 
ment of  speech  defectives  is  undoubtedly  the  training.  This  can 
not  begin  too  early.  The  child  should  have  the  best- model  as 
an  example  of  speech,  and  the  imitative  faculty  should  be  trained 
and  developed.  All  "cute"  baby  talk  should  be  discouraged, 
and  only  good  forms  of  speech  encouraged. 

CROUP. 

Synonyms. — CATARRHAL  LARYNGITIS  ;    FALSE  OR  SPASMODIC 

CROUP. 

Simple  spasmodic  croup  is  to  be  differentiated  from  catarrhal 
laryngitis. 

Catarrhal  croup,  or  acute  catarrhal  laryngitis,  is  an  inflam- 
matory affection  of  the  larynx  and  trachea,  noncontagious  in 
nature,  and  excited  by  an  acute  catarrh.  The  most  conspicuous 
feature  is  the  "croup,"  or  loud  cry,  or  ringing  metallic  cough. 
It  is  usually  followed  by  tracheitis  or  bronchitis.  It  may  be 
primary,  secondary  to  the  infectious  diseases,  or  traumatic.  The 
lesions  are  found  chiefly  in  the  mucosa  and  lymphoid  tissue  of 
the  subglottic  region,  and  in  severe  cases  they  may  be  so  serious 
as  to  produce  laryngeal  stenosis. 

Croup  is  one  of  the  commonest  of  the  respiratory  diseases  of 
early  childhood,  occurring  at  any  time,  but  usually  in  the  change- 
able weather  of  autumn  and  spring.  It  may  be  mild  or  severe, 
and  is  of  importance  chiefly  because  of  the  uncertainty  of  the 


CROUP.  44 1 

diagnosis,  as  well  as  the  distress  that  it  occasions  to  the  family 
and  the  anxiety  felt  by  the  physician,  who,  be  he  ever  so  skilful, 
not  seldom  fails  to  make  a  correct  diagnosis  on  his  first  visit. 
We  are  called  upon  to  distinguish,  then,  between  this  false  croup 
and  true  or  membranous  croup,  between  false  croup  and  laryn- 
geal  diphtheria, and  between  false  croup  and  laryngismus  stridulus. 
False  croup  is  a  common  malady  and  so  is  diphtheria  ;  the  others 
are  comparatively  rare.  False  croup  occurs  in  isolated  instances, 
although  several  members  of  a  family  may  be  so  predisposed. 
It  is  never  communicated  and  is  noncontagious.  Sporadic  cases 
of  diphtheria  are  not  uncommon. 

The  causes  are  age,  commonly  between  two  and  five  years, 
neurotic  heredity,  enlarged  tonsils,  adenoid  growth  of  the  phar- 
ynx, exposure  to  cold,  dampness,  and  disturbances  of  digestion. 

Symptoms. — These  diseases  with  the  symptoms  common  to 
croup  come  on  suddenly,  with  a  more  or  less  well-defined  pro- 
dromal stage  ;  perhaps  none  at  all.  The  earlier  symptoms, 
before  the  sudden  attack,  are  usually  a  slight  coryza,  hoarseness, 
and  cough,  with  redness  of  the  fauces  and  feverishness  or  slight 
fever.  True  croup  is  a  rare  disease,  and  there  is  much  doubt  as 
to  whether  it  is  or  is  not  simply  a  form  of  diphtheria.  Jacobi 
does  not  speak  of  membranous  croup  at  all,  but  classifies  pseu- 
domembranous  croup  and  laryngitis  together.  There  are  points 
of  difference  clinically  between  these  two  diseases,  but  not 
enough  to  make  us  always  certain.  There  is  evidence  to 
show — and  this  adduced  by  competent  clinical  observers,  sup- 
ported in  their  views  by  excellent  pathologists — that  instances 
of  false  membrane  in  the  larynx  may  be  anatomically  the  same, 
but  not  a  true  diphtheria  (presenting  the  Klebs-Loeffler  bacillus), 
or  may  be  caused  by  some  other  agency.  False  croup  comes  on 
suddenly  or  may  be  preceded  some  hours  or  a  day  or  two  by 
catarrhal  symptoms  and  slight  fever.  Sometimes  the  larynx 
and  trachea  are  involved  ;  there  is  cough,  but  without  stridor  or 
spasm.  The  attack  usually  begins  in  the  night,  with  almost  no 
warning,  except,  perhaps,  the  cough,  which  changes  and  becomes 
short,  deep-toned,  and  barking,  with  a  peculiar  resonant  quality 
readily  recognizable  ;  the  inspirations  have  a  whistling,  crowing 
sound ;  the  little  one  exhibits  surprise  or  terror,  sits  up  in  bed, 
clutches  at  nearby  objects,  especially  its  mother,  and  seems  to 
experience  some  relief  in  holding  on  to  objects,  the  way  asthmat- 
ics do,  which  enables  the  ribs  to  become  more  vertical,  thus 
assisting  in  securing  a  deeper  inspiration.  There  may  be  extreme 
recession  of  the  thoracic  spaces.  The  cough  has  a  metallic, 
hard  quality,  associated  with  dyspnea,  which  lasts  for  perhaps 


442  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

just  a  moment,  or  a  little  longer,  when  it  lessens,  and  the  child 
may,  in  half  an  hour  or  so,  have  entirely  recovered  and  quieted 
down  to  sleep.  The  attack  is  not  likely  to  be  repeated  more 
than  once  or  twice  at  most ;  but  several  times  during  the  night 
the  short  barking  cough  may  recur.  Next  morning  the  child  is 
apparently  well,  with  the  exception  of  the  cough,  which  usually 
remains.  The  attack  may  return  on  several  successive  nights, 
but  this  is  rare.  Recurrences  are  more  likely  to  be  due  to  lar- 
yngismus  stridulus  or  neuroses,  and  occur  chiefly  in  rachitic 
children.  The  temperature  may  be  little  above  normal,  or  about 
101°  or  102°  F.;  some  observers  report  a  much  higher  temper- 
ature. 

Diagnosis. — In  both  false  croup  and  true  croup  (membranous 
croup)  the  onset  is  sudden  and  generally  accompanied  by  fright 
and  dyspnea,  but  without  delirium  or  convulsions.  In  diph- 
theria, of  whatsoever  form,  there  is  no  fright,  and  there  are 
liable  to  be  convulsions  and  profound  debility.  True  croup 
generally  begins  with  a  chill,  followed  by  fever,  rising  sometimes 
quite  high — 102°  to  103°  F.  at  the  onset  and  up  to  104°  to 
105°  F.  at  the  period  of  greatest  intensity.  False  croup  is  often 
preceded  or  accompanied  by  symptoms  of  disordered  digestion, 
and  after  the  attack  subsides  the  child  is  as  well  as  ever,  whereas 
in  true  croup  and  diphtheria  there  is  marked  depression  during 
convalescence.  In  false  croup  the  child  declines  to  take  nour- 
ishment, more  because  of  the  disturbed  condition  of  the  nervous 
system  than  of  any  pathologic  local  condition  in  the  digestive 
organs,  and  cathartics  are  usually  indicated  and  produce  no 
overeffect  or  depression.  In  diphtheria  cathartics  are  liable  to 
induce  considerable  debility.  The  invasion  of  the  larynx  in 
diphtheria  is  not  so  abrupt,  and  usually  takes  place  through 
extension  from  the  fauces,  and  the  stridulous  breathing,  both  upon 
inspiration  and  expiration,  is  gradually  established.  The  larynx 
may  be  primarily  involved,  making  the  diagnosis  at  first  more 
difficult  ;  yet  it  is,  as  a  rule,  not  so  sudden  as  in  false  croup. 
In  false  croup  the  stridor  and  dyspnea  are  more  or  less  parox- 
ysmal on  inspiration,  and  are  relieved  by  emetics  and  nauseants, 
usually  disappearing  on  the  second  or  third  day.  The  hoarse- 
ness and  aphonia  gradually  subside,  more  slowly  than  the  dysp- 
nea, and  after,  and  perhaps  by  reason  of,  the  action  of  emetics. 

Death  is  very  rare  from  false  croup.  Young  children  and 
those  who  are  of  neurotic  ancestry  are  more  frequently  attacked, 
and  although  they  may  be  enjoying  at  the  time  their  ordinary 
health.  In  diphtheria  disturbances  in  the  voice  remain  and 
steadily  increase,  becoming  oftentimes  a  persistent  whisper.  A 


CROUP.  443 

person  of  experience  can  make  a  decision  from  the  breathing 
sounds,  which  should  always  lead  to  the  use  of  antitoxin  as  a 
remedy.  False  croup  usually  attacks  children  beyond  one  year 
and  up  to  five  or  six,  and  rarely  after  ten  years.  Diphtheria 
attacks  much  the  same  class  of  cases,  although  it  may  occur  in 
younger  and  is  frequent  in  older  children.  The  collateral 
symptoms  common  in  diphtheria  must  be  watched  for — albu- 
min uria,  lymphatic  engorgement,  and  paralysis.  A  bacteriologic 
examination  must  be  made  in  every  case  without  delay,  and 
should  be  repeated  and  is  the  only  test  to  be  relied  on.  Laryn- 
gismus  stridulus  is  a  neurosis  without  catarrhal  symptoms  which 
occurs  in  rachitic  children,  and  which  recurs  in  paroxysms  at 
almost  any  hour.  It  may  accompany  tetany  or  convulsions. 

Treatment  of  Spasmodic  Croup. — The  treatment  of  croup 
is  simple  but  imperative.  The  child  should  be  kept  in  one  well- 
ventilated  room,  with  an  equable  and  distinctly  moist  tempera- 
ture. The  clothing  should  be  sufficient,  lest  chill  should  occur. 
The  bowels  should  be  open  in  almost  any  event,  calomel  being 
the  best  remedy,  although  castor  oil  or  salines  may  be  used. 
The  food  had  best  be  fluid,  such  as  milk,  guarded  by  alkaline 
water,  or  thin  gruels  or  soups.  For  the  milder  varieties  ipecac 
should  be  used  to  the  point  of  nausea  or  full  relaxation  ;  it  is 
well  to  combine  this  with  soda,  the  powdered  ipecac  being 
preferable,  although  the  syrup  form  is  satisfactory.  Ipecac  may 
be  given  with  calomel  in  minute  doses  eveiy  fifteen  minutes  in 
a  powder  on  the  tongue,  and  this  it  is  well  to  combine  with  a 
little  soda.  For  a  baby  of  a  year  or  two,  -^  of  a  grain  of 
calomel,  -^j-  of  a  grain  of  ipecac,  ^  of  a  grain  of  soda,  with  a 
little  sugar  of  milk,  may  be  given  dry  upon  the  tongue  every 
fifteen  minutes.  It  is  not  wise  to  use  severer  depressants  unless 
the  fever  runs  high,  when  aconite,  one-half  to  one  drop  every 
fifteen  minutes,  is  of  great  utility,  and  is  safe  because  of  the  ease 
with  which  its  administration  can  be  regulated.  Antipyrin  is 
useful  in  cases  requiring  nervous  and  arterial  sedatives  and  when 
there  is  decided  increase  of  mucous  secretion.  With  the  anti- 
pyrin  it  is  well  to  give  a  few  drops  of  brandy  or  some  other 
alcoholic  stimulant. 

For  a  child  two  years  old  antipyrin,  ^  to  I  grain,  syrup  of 
ipecac,  2  to  4  drops,  sodium  bicarbonate,  I  grain,  brandy,  6  to  12 
drops,  may  be  given  every  half-hour  to  one  hour  during  the  se- 
verity of  the  attack  or  during  the  night,  and  at  longer  intervals 
during  the  following  day.  Pilocarpin  is  recommended  but  is 
dangerous,  as  it  is  too  depressing  to  the  heart  ;  nevertheless  it  is 
sometimes  of  manifest  value,  especially  in  older  children.  Anti- 


444  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

mony  is  not  to  be  used,  except  possibly  in  vigorous  older  chil- 
dren, and  then  with  caution.  There  are  times  when  opiates  are 
distinctly  useful  to  allay  excitement  or  distressing  cough,  but 
they  are  not  to  be  repeated  too  frequently,  one  or  perhaps  two 
doses  being  sufficient  to  relieve  a  violent  paroxysm.  A  piece  of 
belladonna  plaster  the  size  of  a  small  coin  is  placed  by  some  on 
each  side  of  the  throat.  To  relax  the  spasm  various  mechanical 
devices  are  useful.  A  hot  poultice  applied  to  the  chest  is  effect- 
ive. A  sponge  wrung  out  of  hot  water  will  do  as  well.  Coun- 
terirritation  to  the  chest  with  oil  and  turpentine  or  camphorated 
oil  is  useful.  Local  cleansing  or  spraying  of  the  nose  or  throat 
is  to  be  recommended  in  some  cases.  If  the  rhinitis  should  be 
severe  or  obstructive,  albolene,  containing  one  grain  of  menthol 
and  five  grains  of  camphor  to  the  ounce,  is  both  soothing  and 
stimulating  to  the  nares.  In  the  case  of  a  nervous  child  the 
bromids  may  aid  in  securing  a  good  night's  sleep  ;  an  opiate, 
however,  is  rather  better,  and  five  to  fifteen  drops  of  syrup  of 
Dover's  powder  acts  nicely.  Kerley  recommends,  also,  to  an 
infant  three  months  old  tartar  emetic,  T^  of  a  grain  ;  ipecac,  •£$ 
of  a  grain  ;  antipyrin,  ^  of  a  grain,  every  hour.  In  severe  laryn- 
geal  spasm  great  relief  is  obtained  by  fumigations  with  calomel, 
vaporized  on  an  ordinary  milk  warmer  and  alcohol  lamp  under  a 
sheet  tent.  The  Ermold  lamp  is  better.  Use  ten  grains  in  ten 
minutes,  and  let  the  child  lie  then  for  twenty  minutes  longer. 
This  produces  a  copious  watery  secretion  from  the  larynx. 

So  much  importance  has  been  claimed  for  the  marvelous  suc- 
cess of  homeopathic  treatment  of  croup  that  we  asked  Dr.  J.  Nich- 
olas Mitchell,  Professor  of  Obstetrics  at  the  Hahnemann  Medical 
College,  to  give  us  a  full  description  of  his  methods,  which  he 
has  most  kindly  done.  We  use  his  own  words  :  "  For  hoarse, 
barking,  dry  cough,  with  fever,  I  use  a  mixture  of  tinct.  aconit. 
napelli  (leaves),  5j  ;  tinct.  spongiae,  3ij;  using  this,  according 
to  the  age  of  the  child,  from  ^  to  2  drops  every  fifteen  minutes 
till  the  cough  loosens.  When  the  cough  is  loose  and  the  phlegm 
is  interfering  with  respiration,  with  occasional  spasmodic,  barky 
cough,  I  mix  one  grain  of  the  one-tenth  trituration  of  hepar 
sulphur,  in  from  four  to  six  teaspoonfuls  of  water,  and  give  one 
teaspoonful  every  fifteen  to  thirty  minutes.  Hepar  sulph.  cal- 
careum  is  an  impure  calcium  sulphid."  We  have  tried  this 
faithfully,  and  with  fair  result. 


MEMBRANOUS  CROUP.  445 

MEMBRANOUS  CROUP. 

Synonyms. — TRUE  CROUP  ;  PSEUDOMEMBRANOUS  LARYNGITIS  ; 
LARYNGEAL  DIPHTHERIA. 

Membranous  croup  is  essentially  the  laryngeal  form  of  diph- 
theria, but  is  not  proved  to  be  always  due  to  the  Klebs-Loeffler 
bacillus.  The  reason  probably  is  that  the  culture  can  not  al- 
ways be  made  from  the  infectious  portion  of  the  exudate.  It 
deserves  to  be  considered  separately  from  the  general  heading 
of  diphtheria  because  of  its  clinical  features,  which  are  those  of  a 
laryngitis.  Diphtheria  of  the  pharynx  presents  a  somewhat  dif- 
ferent onset,  features,  and  course.  True  croup  appears  suddenly, 
with  a  series  of  phenomena  oftentimes  endangering  life  by  me- 
chanical obstruction  before  the  constitutional  symptoms  obtrude 
themselves  at  all.  Absorption  from  the  larynx  is  feebler  and 
slower  than  from  the  pharynx  ;  hence  glandular  enlargement 
and  albuminuria  are  uncommon,  nor  is  there  the  striking  asthenia 
seen  in  cases  of  genuine  toxemia  from  diphtheria.  Postmortem, 
the  structural  degeneration  in  the  viscera  common  in  diphtheria 
is  usually  wanting.  Contagion  is  feeble — because  the  discharges 
from  the  throat  and  nose  are  less  or  are  absent — and  the  course 
is  shorter.  In  short,  the  forms  of  diphtheria  vary  so  widely  that 
there  may  be  instances  where  it  can  not  be  detected  except  by 
the  secondary  phenomena  and  complications. 

Symptoms. — True  croup  differs  little  in  its  onset  from  false 
croup  or  catarrhal  laryngitis,  except  that  it  is  slower  or  not  quite 
so  abrupt  nor  so  severe  at  first.  There  is  the  same  high-pitched, 
ringing  cough,  hoarse  voice,  general  discomfort,  and  quick  but 
not  weak  pulse.  The  catarrhal  phenomena  are  less  marked  or 
absent.  Dyspnea  increases  slowly,  and  under  excitement  be- 
comes profound,  and  alarms  both  parents  and  child.  The  tem- 
perature is  seldom  high — between  99°  and  100°  F.,  or  a  little 
over ;  the  skin  is  pale  and  moist,  and  as  obstruction  progresses 
— steadily,  as  a  rule,  differing  from  false  croup — the  surface 
grows  cyanotic.  Breathing  becomes  much  more  difficult  on  the 
second  and  third  days,  and  is  accompanied  by  all  the  distressing 
features  which  follow  this  state — tossing,  restlessness,, irritability, 
etc.  The  child  seizes  on  to  objects  to  aid  the  respiratory  action 
by  muscular  efforts. 

The  respiratory  sounds  become  rough,  without  vesicular  mur- 
mur. The  symptoms,  if  unrelieved  by  treatment,  progress  from 
bad  to  worse,  the  temperature  rises  to  104°  or  106°  F.,  and 
death  ensues  by  strangling,  convulsions,  or  coma. 

We  reported  a  typical  case  in  which  the  symptoms  rapidly  grew 


MEMBRANOUS    CROUP.  447 

alarming,  and  intubation  was  performed  by  Dr.  Freeman.  The 
cough  became  so  extreme  that  the  junction  of  two  ribs  with  the 
costal  cartilages  parted,  producing  hernia  of  the  lung,  which  was 
cured  by  strapping.  In  this  case  the  earlier  bacteriologic  exami- 
nations showed  no  Loeffler  bacilli,  but  analysis  of  the  material 
on  the  tube,  when  removed  eight  days  after  the  operation  of  in- 
tubation, showed  them  to  be  abundant ;  yet  at  no  time  was  there 
a  large  amount  of  membrane. 

The  prognosis  of  true  croup  depends  on  the  age  of  the  patient 
and  the  character  of  the  epidemic.  In  untreated  cases  the  mor- 
tality is  very  high. 

Diagnosis  is  to  be  made  by  careful  examination,  which  in- 
volves exploring  the  larynx  by  the  finger  to  exclude  retropharyn- 
geal  abscess  and  foreign  bodies.  The  suddenness  of  the  onset 
of  true  croup  is  not  so  great  as  in  false  croup  nor  in  the  above- 
mentioned  states,  yet  it  may  arise  most  swiftly.  Bronchopneu- 
monia  has  a  higher  temperature,  as  a  rule,  and  characteristic 
signs  in  the  chest.  The  form  of  dyspnea  is  different  too.  The 
child  is  quieter  ;  in  spasmodic  croup  it  is  restless  and  struggles. 

Treatment. — Nauseants  should  never  be  used,  but  antitoxin 
should  be  administered  at  once,  in  a  full  dose — 2000  units  or 
more.  (See  Diphtheria.) 

Nowhere  is  the  serum  treatment  so  efficacious  as  in  these  cases. 
Inhalation  of  steam  is  a  useful  adjuvant ;  so,  especially,  are  calo- 
mel fumigations.  The  tent  should  be  applied  at  once  and 
Ermold's  lamp  put  in  operation  or  the  practical  plan  suggested 
by  Holt.  This  is  to  take  an  ordinary  chamber-pot,  and  place 
over  the  top  of  this  a  strip  of  tin  ;  on  this  is  placed  the  calomel 
(ten  or  fifteen  grains),  and  beneath  it  an  alcohol  lamp,  with  the 
flame  in  contact  with  the  metal.  Soon  the  white  vapor  of  mer- 
cury rises  and  fills  the  tent ;  and  this  should  be  kept  up  from  ten 
to  fifteen  minutes.  (Care  must  be  exercised  not  to  let  this  be 
knocked  over  by  the  child  and  cause  a  conflagration.)  This 
may  be  repeated  every  hour  or  two,  according  to  the  needs  of 
the  case.  It  affords  marked  relief  in  most  cases.  After  the 
calomel  has  been  used  the  tent  should  be  removed  and  the  room 
aired.  Sometimes  vaporized  mercury  causes  choking,  if  in  too 
concentrated  a  form.  Salivation  is  rare,  but  may  occur  among 
the  attendants,  who  should  be  warned  not  to  put  their  heads 
under  the  tent.  Relief  is  seen  usually  after  the  second  or  third 
fumigation.  It  should  be  begun  as  soon  as  the  croup  is  diag- 
nosticated, before  dyspnea  becomes  marked.  The  operation  of 
tracheotomy  and  intubation  to  relieve  the  obstruction  of  false 
membrane  in  the  larynx  must  not  be  delayed  ;  certainly  not  until 


448  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

cyanosis  sets  in,  which  may  only  occur  just  before  death.  Before 
the  use  of  antitoxin  the  mortality  was  30  to  40  per  cent,  from 
these  operations.  Now  it  is  much  less,  and  decreasing  steadily, 
partly  because  of  the  enormous  help  afforded  by  antitoxin,  which 
is  peculiarly  helpful  to  this  class  of  cases,  and  partly  because  the 
operation  of  intubation  is  more  promptly  and  skilfully  performed. 
This  usually  suffices,  but  occasionally  tracheotomy  is  made  to 
supplement  the  intubation  when  that  is  insufficient  to  afford 
relief. 

LARYNGISMUS  STRIDULUS. 

Laryngismus,  laryngospasm,  spasm  of  the  glottis,  or  rachitic 
asthma  is  a  disorder  characterized  by  paroxysmal  narrowings  of 
the  glottis,  accompanied  by  spasmodic  disturbances  of  respira- 
tion, occurring  and  recurring  at  intervals.  It  is  a  neurosis  of  the 
larynx,  which  is  otherwise  healthy.  It  should  not  be  confounded 
with  false  croup  (spasmodic  laryngitis),  infantile  asthma,  nor 
internal  convulsions,  and  is  rather  a  complication — at  least,  fre- 
quently— of  other  disorders.  The  paroxysm  is  produced  by  a 
spastic  contraction  of  the  muscles  which  narrow  the  glottis, 
occurs  always  during  inspiration,  and  results  from  irritation  of 
the  recurrent  laryngeal  nerve  or  of  the  pneumogastric.  It  is 
asserted  by  some  authorities  to  be  a  characteristic  symptom  of 
latent  tetany.  Laryngismus  stridulus  is  a  disorder  of  infantile 
life,  usually  from  the  fourth  to  the  fourteenth  month,  and  rarely 
beyond  the  third  year.  The  children  attacked  present  many 
marks  of  neurosis  and  irritability.  The  disease  prevails  in  the 
cold  months  and  among  those  too  much  confined  indoors. 

Causes. — The  causes  are  constitutional  and  local.  It  is  quite 
well  established  that  the  constitutional  disorder  known  as  rickets 
is  at  the  bottom  of  most,  if  not  all,  of  the  cases  of  laryngospasm, 
and  two-thirds  of  the  children  affected  present  well-marked  evi- 
dences of  rickets.  In  rachitic  infants  nervous  irritability  is  gen- 
erally exaggerated  ;  in  them  slight  exciting  causes — emotional, 
exposure,  and  catarrhal — readily  produce  morbid  respiratory 
conditions.  Hereditary  predisposition  is  blamed  by  some,  but 
this  is  scarcely  more  than  can  be  explained  by  the  neurotic  con- 
stitution and  impaired  nutrition.  Local  causes  are  numerous, 
but  chiefly  in  the  line  of  digestive  disturbances,  protracted  or 
acute.  Pressure  from  enlarged  glands  and  diseases  of  the  heart 
and  liver  are  now  and  then  exciting  causes,  as  is  also  confinement 
in  a  vitiated  atmosphere. 

Symptoms. — The  laryngospasm  begins  suddenly  at  night  in 
a  child  otherwise  apparently  healthy,  who  then  gasps  for  breath 


LARYXGISMUS    STRIDULUS.  449 

and  becomes  rigid,  throwing  the  head  far  back.  The  face  be- 
comes cyanotic,  pale,  or  dusky  ;  a  cold  sweat  breaks  out,  and, 
after  a  brief  interval,  a  few  whistling  or  crowing  inspirations  are 
heard.  The  breathing  again  becomes  "  locked,"  and  presently 
the  child,  straining  to  get  its  breath,  reproduces  the  whistling 
sounds.  This,  repeated  two  or  three  times,  is  followed  by  expi- 
ration, a  vigorous  cry,  and  the  breathing  again  becomes  estab- 
lished. The  glottis  may  be  completely  closed,  and  the  muscles 
of  the  thorax  and  diaphragm  tense  ;  if  the  closure  be  incomplete, 
attempts  to  in-breathe  are  laborious  and  noisy,  as  described.  The 
effect  of  the  strain  is  shown  upon  the  heart's  action  ;  if  severe, 
consciousness  may  be  lost,  and  the  urine  and  feces  voided  invol- 
untarily. The  seizures  vary  in  severity  and  in  number ;  the 
milder  ones  may  pass  without  much  distress.  The  number  of 
attacks  varies  from  a  few  to  thirty  or  forty  in  the  twenty-four 
hours.  If  the  spasm  continues  longer  than  a  minute  or  two,  death 
is  likely  to  result.  The  paroxysms  may  occur  as  readily  in  the 
daytime  as  in  the  night.  There  is  no  accompanying  fever  unless 
some  other  disease  supervenes.  Dyspeptic  symptoms  are  nearly 
always  present.  As  the  disorder  progresses  spasmodic  phenomena 
occur,  very  often  in  other  parts  of  the  body,  the  most  frequent  of 
which  is  the  indrawing  of  the  thumbs  and  the  upward  turning  of 
the  great  toe — "  carpopedal  spasm."  The  foot  is  sometimes 
drawn  up  against  the  shin,  and  the  hands  are  sometimes  bent 
upon  the  forearm.  The  course  of  laryngismus  stridulus  is  irreg- 
ular, the  attacks  occurring  at  intervals  of  varying  length  and 
severity  ;  the  course  usually,  however,  "  runs  a  circuit  of  aggrava- 
tion, climax,  and  diminution."  The  duration  is  uncertain,  and 
the  first  attack  may  prove  fatal  in  a  few  hours,  or  it  may  last  or 
recur  for  months.  The  complications  of  laryngospasm  are  very 
numerous,  involving  sometimes  the  membranes  of  the  brain  ; 
oftentimes,  also,  there  arise  catarrhs  of  the  lungs,  bronchial  tubes, 
larynx,  and  intestines. 

Diagnosis. — Laryngospasm  is  rare  in  America,  and  so  sudden 
and  brief  is  the  seizure  and  so  free  from  disturbance  the  intervals 
that  there  should  be  little  difficulty  in  recognizing  the  disorder. 
It  is  accompanied  by  no  fever,  change  of  voice,  catarrhal  symp- 
toms, or  cough  ;  therefore  there  is  no  occasion  to  mistake  it  for 
croup  or  other  organic  disease  of  the  larynx.  It  somewhat 
resembles  false  croup,  but  the  clinical  history  is  quite  different. 

Prognosis. — The  prognosis  varies,  but  is  never  good,  a  large 
proportion  of  cases  ending  fatally.  This  is  not  strange  when  one 
reflects  upon  the  enfeebled  conditions  of  those  in  whom  it  occurs. 

Treatment. — The  important  element  of  treatment  is  constitu- 
29 


4 SO  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

tional  repair,  and  this  is  treated  of  at  length  under  rickets  and 
developmental  methods.  The  digestion  in  most  sufferers  is  con- 
spicuously bad,  and  needs  careful  regulation.  For  the  relief  of 
the  spasm  a  host  of  remedies  are  advised,  the  best  of  which  are 
local  or  general  counterirritants  in  the  shape  of  cold  or  heat, 
baths,  and  volatile  substances  applied  to  the  nose.  In  extreme 
apnea  relief  is  afforded  by  placing  the  child  in  a  hot  bath  and 
dashing  cold  water  on  its  face  and  chest,  or  a  hot  mustard  foot- 
bath with  ice  compresses  to  the  head  and  neck.  Strong  currents 
of  electricity,  especially  faradism,  to  the  chest  and  larynx  may 
stimulate  breathing.  If  death  be  imminent,  blowing  into  the 
lungs  is  sometimes  effective,  or  intubation  may  be  demanded. 
Tracheotomy  is  to  be  avoided.  Artificial  respiration  is  of  use. 
The  bowels  should  be  promptly  unloaded  by  an  enema  of  water 
or  glycerin  ;  if  time  allows,  a  dose  of  castor  oil  or  calomel  should 
be  given.  Of  depressomotor  remedies,  musk  is  said  to  be 
best ;  next  come  the  bromids,  valerian,  and  chloral  hydrate, 
but  opium  should  be  used  with  great  care.  The  dose  of  musk 
is  from  a  grain  to  two  grains  in  the  syrup  of  lactucarium,  or  it 
may  be  given  in  the  form  of  the  tincture  of  musk — from  five  to 
twenty  drops.  During  the  interval  tonics  should  be  used,  and  it 
is  well  to  bear  in  mind,  as  Jacobi  points  out,  that  in  rachitis, 
while  the  heart  may  be  of  average  size,  the  arteries  are  abnor- 
mally large,  thus  lowering  blood  pressure,  and  the  circulation  in 
the  respiratory  organs  is  slow  and  sluggish,  tending  to  produce 
congestion  and  catarrh ;  therefore  it  is  advisable  to  add  cardiac 
tonics,  as  strophanthus,  digitalis,  or  spartein  sulphate.  Many 
cases  bear  well  ^  of  a  grain  of  codein  in  a  day.  General  con- 
vulsions are  liable  to  follow  the  attack,  and  for  this  the  cautious 
inhalation  of  chloroform  or  a  rectal  injection  of  from  four  to  eight 
grains  of  chloral  hydrate  may  afford  relief.  (See  Convulsions, 
Treatment  of,  p.  509.) 

COUGH. 

The  causes  of  cough  are  those  conditions  capable  of  produc- 
ing pulmonic  irritation,  and  the  act  of  coughing  usually  begins  in 
the  respiratory  mucous  membranes.  The  utility  of  coughing  is 
to  expectorate  the  material  which  offends  this  surface,  such  as 
foreign  bodies,  mucus,  or  pus.  Cough  accompanies  all  forms  of 
bronchitis,  and  such  affections  of  the  lungs  as  have  a  bronchitis 
associated  with  them.  The  cough  of  phthisis  is  due  to  a  local- 
ized bronchial  catarrh  or  to  a  laryngeal  irritation.  This  irrita- 
tion may  arise  in  any  portion  of  the  respiratory  tract.  Cough  is 
especially  prominent  in  diseases  of  the  pharynx  and  larynx.  The 


COUGH.  45 1 

cough  of  laryngeal  irritation  is  recognizable  and  characteristic. 
The  presence  of  a  foreign  body  in  or  about  the  respiratory  pas- 
sages does  not  necessarily  or  always  produce  a  cough,  as  when 
the  sensitiveness  of  the  parts  or  the  general  blunting  of  the  sen- 
sibilities reduces  the  physiologic  irritability.  This  occurs  in  certain 
diseases  of  the  brain  and  in  the  stupor  induced  by  high  temper- 
atures, especially  in  the  infectious  diseases.  When  in  a  grave 
pneumonia  or  the  late  stages  of  tuberculosis  of  the  lungs  the 
cough  subsides,  it  is  ground  for  much  anxiety.  Cough  may  also 
be  of  centric  origin.  Irritation  of  the  floor  of  the  fourth  ven- 
tricle above  the  center  of  respiration  excites  a  cough.  Foreign 
bodies  in  the  meatus  of  the  ear  often  excite  a  cough ;  so  does 
disease  of  the  ear.  Infants  during  the  first  dentition  sometimes 
cough  as  the  teeth  erupt.  It  is  common  for  a  decayed  tooth  to 
induce  the  same  reflex  disturbance.  The  cough  which  accom- 
panies gastro-intestinal  disturbances  and  which  often  is  known  to 
leave  promptly  when  the  condition  is  relieved  is  probably  due  to 
the  secondary  pharyngitis  induced. 

Cough  may  be  dry  or  moist ;  constant  or  paroxysmal.  The 
cough  is  dry  when  the  cause  of  the  irritation  can  not  be  readily 
or  promptly  removed. 

A  dry  cough  is  heard  in  the  first  stages  of  bronchitis  and  in 
phthisis.  Pleurisy  at  first  induces  a  short,  hacking,  suppressed 
cough  ;  later  it  is  superficial  and  is  always  characteristic.  The 
cough  of  ear  trouble  or  dental  irritation  is  not  unlike  it.  The 
cough  of  emphysema  is  often  dry  for  a  period,  and  later  only 
ceases  after  the  dislodgement  of  a  small  mass  of  mucus.  The 
nervous  cough  is  also  dry  in  character.  Moist  cough  is  accom- 
panied by  the  output  of  mucous,  mucopurulent,  or  bloody  serum. 

A  constant  cough  implies  persistence  of  the  cause  and  is  pul- 
monary. This  is  heard  in  pleurisy,  phthisis,  bronchitis,  and 
pulmonary  consolidations.  A  paroxysmal  cough  is  one  in 
which  the  irritation  recurs,  or  the  resistance  is  limited  and  may 
be  of  reflex  or  central  causation.  This  recurring  condition 
accompanies  cavity  formation  in  the  lung,  or  where  the  pleura 
opens  into  the  lung  and  lessens  as  the  cavity  becomes  emptied 
and  recurs  as  it  becomes  filled  again. 

If  accompanied  by  vomiting  or  retching,  it  is  a  ground  for 
suspicion  of  pertussis  or  phthisis.  Pertussis  is  evidenced  by 
paroxysms  of  coughing  which  are  often  followed  by  vomiting  or 
retching,  and  the  sufferers  also  exhibit  a  congested  and  anxious 
appearance  of  the  face,  with  staring  eyes,  clutching  at  the  side, 
etc.,  and  followed  by  a  long-drawn  forceful  inspiration  or 
"  whoop." 


452  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

ACUTE  BRONCHITIS. 

Bronchitis  is  an  inflammation  of  the  bronchial  mucous  mem- 
brane of  the  large  and  small  tubes,  due  to  many  causes,  and  is 
rather  a  symptom  than  a  disease.  Capillary  bronchitis,  or  a 
catarrh  of  the  smallest  tubes,  is  no  longer  used  as  a  division  of 
the  disorder,  but  is  an  integral  part  of  bronchopneumonia. 
These  final  ramifications  can  scarcely  be  affected  without  also 
involving  the  alveoli.  The  only  practical  division  is  into  mild 
and  severe  cases  of  bronchitis. 

Causes. — Acute  bronchitis  is  common  in  children  as  the  re- 
sult of  cold  and  exposure.  It  occurs  most  frequently  late  in  the 
autumn  and  early  in  the  spring,  when  changeable  weather  is 
prevalent.  Bronchitis  also  accompanies  a  large  number  of  in- 
fectious diseases,  especially  in  children,  in  whom  the  bronchial 
mucous  membrane  is  peculiarly  susceptible  to  congestion,  as  in 
typhoid  fever,  measles,  whooping-cough,  influenza,  diphtheria, 
Rotheln,  and  scarlatina.  In  infants  it  is  also  a  common  accom- 
paniment of  dentition,  and  where  there  is  a  lowered  condition  of 
nutrition  present,  as  in  rachitis.  Here  it  is  more  likely  to  be  the 
feebleness  of  the  individuals  which  renders  them  extremely  sus- 
ceptible. Irritating  gases  or  substances  introduced  into  the 
bronchi  mechanically  induce  a  bronchial  catarrh  ;  also  any  form 
of  lung  degeneration,  notably  tuberculosis.  Bronchitis  is  also 
a  common  symptom  of  septicemia,  and  a  special  variety  has 
been  pointed  out  coexisting  with  putrid  diarrhea.  It  is  seen  in 
diseases  of  the  kidneys,  where  it  may  result  from  toxins  or  may 
evidence  pulmonary  edema.  Frequently  recurring  bronchitis  is 
very  likely  to  have  its  origin  in  enlarged  bronchial  glands.  No 
one  bacillus  can  be  claimed  as  the  specific  cause  of  this  disorder. 

Pathology. — The  anatomic  changes  in  acute  bronchitis  are 
practically  the  same,  from  whatever  cause.  Owing  to  the  swell- 
ing of  the  mucous  membrane,  the  lumina  of  the  trachea  and 
bronchi  become  smaller.  There  is  temporary  functional  arrest 
of  the  action  of  the  mucous  glands,  with  subsequent  increase  in 
their  activity. 

As  the  congestion  diminishes  desquamation  of  the  ciliated 
epithelium  in  the  mucosa  and  swelling  of  the  submucosa,  with 
infiltration  of  the  leukocytes,  take  place.  The  pathologic 
changes,  as  a  rule,  are  confined  to  the  mucous  membrane,  pro- 
ducing no  change  beneath  it,  unless  the  case  is  protracted,  when 
there  may  be  slight  thickening  of  the  walls.  Should  the  smaller 
bronchi  be  affected,  occlusion  may  result,  with  collapse  of  the 
alveoli  supplied  by  them ;  hence  supervenes  a  general  collapse, 


ACUTE    BRONCHITIS.  453 

more  particularly  in  infants,  where  the  catarrhal  products  there 
heaped  together  produce  unusual  troubles — emphysema  or  al- 
veolar catarrh.  During  the  earlier  stages,  when  the  cough  is 
spoken  of  as  "  tight,"  the  epithelium  after  the  primary  conges- 
tion accumulates  along  with  little  moisture,  and  as  these  cells 
are  not  then  reproduced,  they  do  not  readily  come  away  in  the 
sputum. 

The  sputum  consists  of  cellular  debris,  of  mucous  plugs  secreted 
from  the  glands  in  the  bronchial  walls,  and  of  mucus  which  has 
been  formed  in  the  epithelial  cells  themselves,  together  with  pus 
cocci. 

Should  there  be  intense  congestion,  the  mucus  may  also  be- 
come blood-streaked,  and  on  examination  of  the  submucosa 
ecchymotic  spots  will  be  found.  The  changes  which  sometimes 
take  place  in  the  character  of  the  secretion  have  led  to  the 
subclassification  into  bronchorrhcea  serosa,  bronchitis  fcetida,  etc. 

The  lymphatic  glands  at  the  root  of  the  tongue  become  en- 
larged, particularly  in  infants  and  young  children — a  point  of 
great  importance.  These  are  liable  to  remain  more  or  less 
engorged  and  to  become  the  starting-point  of  subsequent 
attacks,  and  while  not  originally  tuberculous,  may  readily  be- 
come so.  This  is  a  large  factor  in  the  production  of  anemia,  in 
delaying  convalescence,  and  in  provoking  micturition. 

In  chronic  bronchitis  the  acute  form  of  the  disease  fails  to 
undergo  resolution ;  the  cellular  infiltration  of  the  fibrous  coat 
continues,  producing  a  thickening  of  the  whole  bronchus  with 
diminution  of  its  caliber,  leading  first  to  hypertrophy  and  then  to 
atrophy  and  impaired  elasticity  and  favoring  the  formation  of 
dilatations.  If  this  process  continues,  the  infiltration  leads  to  the 
formation  of  fibrous  tissue,  resulting  in  interstitial  pneumonia,  and 
the  contraction  of  this  produces  (especially  when  formed  in  the 
interlobular  septa)  a  dilatation  of  the  tubes,  known  as  bronchiec- 
tasis.  Chronic  bronchitis  is  always  accompanied  by  more  or  less 
atelectasis  and  emphysema. 

Symptoms. — The  first  symptom  of  a  mild  bronchitis  in  very 
young  children  is  usually  a  coryza,  slight  catarrh  of  the  upper 
respiratory  passages,  some  elevation  of  temperature, — 100°  to 
101°  F., — and  a  hard,  dry  cough  of  more  or  less  severity,  less- 
ened appetite,  some  evidence  of  discomfort,  referred  to  the  chest 
or  stomach,  slightly  hurried  respiration,  and  quickened  pulse. 
The  pulmonary  resonance  is  normal ;  a  few  sibilant  or  sonorous 
rales  may  be  heard  near  the  middle,  posteriorly,  the  state  lasting 
from  two  to  three  days.  When  the  mucus  becomes  more  moist, 
and  as  recovery  advances,  there  is  a  looser  and  less  constant 


454  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

cough,  along  with  increased  expectoration  and  greater  liveli- 
ness. 

Expectoration  is  not  possible  in  infants,  and  is  only  an  acquired 
capacity  of  later  years — at  six  or  seven  ;  the  mucus  is  therefore 
swallowed,  producing  more  or  less  intestinal  discomfort  and  tend- 
ing to  excite  reflex  cough. 

If  the  temperature  should  run  above  101°  F.,  and  especially 
if  it  remains  high  beyond  the  third  or  fourth  day,  a  critical  search 
should  be  made  for  evidences  of  bronchopneumonia.  Before  this 
can  be  determined  we  may  have  a  group  of  symptoms  which  are 
common  to  severer  bronchitis  and  to  the  pneumonic  extension — 
a  dilatation  of  the  alse  nasi  on  inspiration,  or  other  evidences  of 
dyspnea,  with  a  sinking-in  of  the  tissues  above  the  sternum  or  of 
the  soft  parts  along  the  insertion  of  the  diaphragm,  and  accom- 
panied by  increased  rapidity  of  respiration  and  pulse.  The  tem- 
perature may  become  high  or  remain  low.  Temperature  change 
in  bronchitis  is  to  be  attributed  to  the  cause  rather  than  to  the 
disease  ;  there  is  no  typical  curve.  If  all  this  again  mitigates  in 
a  day  or  two,  apprehension  lessens  as  to  a  deeper  extension  of 
the  catarrh,  even  though  there  be  pronounced  nervous  phenomena 
with  grunting  expiration  and  evidence  of  much  pain  on>cough- 
ing.  Anxiety  is  caused  by  a  protraction  of  these  symptoms  ; 
particularly  if  there  be  more  or  less  temperature  elevation,  with 
an  increased  proportion  of  respiration  over  pulse-rate,  a  tendency 
for  the  infant  or  child  to  become  apathetic,  along  with  a  cool, 
moist  skin,  we  may  anticipate  rinding  evidences  of  bronchopneu- 
monia upon  exploration  of  the  chest. 

Prognosis. — The  prognosis  depends  upon  the  cause  which 
has  produced  the  disease,  and  must  be  estimated  in  the  light  of 
the  previous  malady.  The  duration  of  a  mild  bronchitis  is 
usually  three  or  four  days,  and  even  when  quite  severe,  rarely 
lasts  more  than  a  week  or  a  week  and  a  half.  That  which 
follows  pertussis  may  last  indefinitely ;  so  in  measles.  The 
situation  of  the  affection  in  the  smaller  or  larger  tubes  is  not  of 
uniform  significance  in  estimating  duration.  If  the  bronchial 
glands  are  enlarged,  we  may  fear  considerable  protraction  and 
ready  recurrence  of  bronchitis,  and  a  danger  of  tubercular  infec- 
tion. If  the  child  is  vigorous  and  appears  well,  the  catarrh  is 
easily  thrown  off  and  the  disease  ends  promptly ;  if  of  lowered 
vitality,  the  disease  lingers,  from  whatsoever  antecedent  cause. 
Constitutional  defects,  as  rickets,  are  most  unfavorable  ;  so, 
indeed,  is  organic  damage,  such  as  cardiac  valvular  disease. 

Bronchiectasis,  or  acute  dilatation  of  the  bronchi,  may  occur, 
due  to  inflammatory  softening  of  the  walls  of  the  lesser  tubes. 


ACUTE    BRONCHITIS.  455 

Aero-emphysema  is  commonly  associated  with  these  dilated 
tubules.  Hence  will  be  found  hyperresonant  areas,  with  pro- 
longed expiratory  murmur. 

Collapse  of  the  lung  may  take  place  occasionally  during  the 
course  of  a  bronchial  catarrh.  The  symptoms  of  collapse  are 
not  always  definite,  but  are  usually  a  distressful  cyanosis,  excited 
struggles  for  breath,  and  possibly  convulsions  and  marked 
asphyxia. 

The  physical  signs  are  not  so  clear.  Percussion  sounds  are 
rendered  obscure  by  closely  associated  areas  of  emphysema 
(dilatations),  with  collapsed  bronchi  and  pneumonic  patches. 
Respiratory  murmur  over  the  collapsed  area  is  weak. 

Diagnosis. — The  diagnosis  of  bronchitis  is  obvious  enough  ;  a 
cough  with  bronchial  secretion  is  not  to  be  mistaken  ;  rales  may 
or  may  not  at  first  be  heard,  and  may  be  few  or  many  on  one  or 
both  sides  of  the  chest ;  later,  when  these  become  moist  and 
more  numerous,  they  are  more  readily  distinguished.  The  im- 
portant points  in  diagnosis  are  to  estimate  the  character  and 
significance  of  the  bronchial  catarrh  in  the  light  of  its  antecedent 
factors  and  the  vigor  of  the  child.  In  a  simple  bronchitis,  of 
howsoever  great  severity,  there  is  no  modification  of  the  percus- 
sion-note, and  in  cases  of  circumscribed  pneumonic  consolidation 
there  may  be  very  little.  The  presence  of  bronchophony  and 
bronchial  breathing  will  aid  us  here. 

Treatment. — The  first  thing  in  treating  bronchitis  is  to  reg- 
ulate surrounding  conditions  or  to  enforce  them  more  vigorously 
where  the  disorder  complicates  an  already  existing  disease.  A 
laxative  is  one  of  the  first  and  most  useful  remedies,  and  the  best 
is  a  dose  of  castor  oil  or  a  simple  saline,  such  as  magnesia.  The 
old-fashioned  combination  of  small  doses  of  Dover's  powder  and 
calomel  at  frequent  intervals  gives  prompt  relief.  Counterirrita- 
tion  to  the  chest  is  also  most  useful  when  applied  thoroughly. 

Next  in  importance  to  the  salubrity  of  the  environment  may 
be  ranked  attention  to  the  digestive  organs.  Food  should  be  of 
the  simplest,  and  taken  slowly  ;  and  milk  and  eggs  rather  than 
meat,  with  possibly  aids  to  digestion  and  antifermentatives.  Cal- 
omel is  useful  as  a  laxative,  to  deplete  the  liver  and  thus  avert 
pulmonary  congestion,  to  stimulate  secretions  of  the  various 
glands,  and  as  a  diuretic ;  it  is  best  given  in  small  doses  and  fre- 
quently. Derivatives  applied  to  the  chest  are  of  recognized 
value,  and  all  means  which  aid  dilatation  of  the  cutaneous  capil- 
laries. Poultices  of  hot  flaxseed  or  cornmeal,  used  posteriorly 
for  half  an  hour  at  intervals  of  three  or  four  hours  for  one  or  two 
days,  removed  carefully  and  followed  by  a  stimulating  application 


DISEASES    OF    THE    RESPIRATORY    ORGANS. 

both  back  and  front,  the  whole  chest  being  covered  in  with  cot- 
ton-wool, is  an  efficacious  treatment  in  our  hands.  One  of  the 
most  important  effects  of  this  procedure  is  to  tranquillize  the 
child,  who  falls  asleep  soon  after  the  first  poultice  and  during  the 
intervals.  The  constant  use  of  the  cotton  jacket  covered  with 
oiled  silk  is  preferred  by  some.  The  counterirritant  may  be  tur- 
pentine, one  dram  to  the  ounce  of  sweet  oil,  or  almond  oil  or 
camphorated  oil  or  soap  liniment.  Oil  of  amber  is  excellent,  or 
croton  oil  diluted.  This  should  be  rubbed  in  with  the  hand 
thoroughly,  in  a  warm  corner  of  the  room,  and  followed  by  a 
special  skin  protection  (as  a  layer  of  cotton-wool).  It  is  sometimes 
well  to  accompany  this  with  a  hot  foot-bath,  which  is  always  a 
wholesome  febrifuge  and  derivative.  As  both  an  expectorant 
and  a  diaphoretic,  hot  drinks  serve  a  useful  turn  when  they  can 
be  administered,  in  which  may  be  put  a  few  drops  of  spirits 
(whisky)  or  sweet  spirits  of  niter,  or  both.  An  emetic  is  exceed- 
ingly efficacious  at  the  start,  especially  ipecac  or  hot  water  and 
salt  (apomorphin  is  too  depressing  for  children).  A  moistening 
of  the  air,  as  under  a  croup  tent,  is  another  valuable  and  prompt 
remedy  often  needed.  Expectorants  are  useful  solely  for  the 
purpose  of  stimulating  bronchial  secretion  when  scanty,  a>nd  when 
the  rales  are  few  and  dry  and  the  cough  frequent  and  harassing. 
Once  secretion  is  thoroughly  established,  their  function  ends. 
The  chlorid  of  ammonium  is  of  some  use  in  keeping  up  thjs 
action,  especially  if  combined  with  a  grain  or  two  of  potassium 
iodid,  and  may  be  continued  with  some  advantage  to  control  an 
accompanying  intestinal  catarrh.  The  coal-tar  antipyretics  are 
also  useful  expectorants,  antipyrin  coming  first,  then  phenacetin 
and  the  others,  and  are  best  accompanied  by  some  alcoholic  prep- 
aration, as  wine  of  pepsin,  elixir  calisaya,  port  or  sherry  wine ; 
of  course,  in  very  small  doses.  It  is  wise  not  to  try  to  check  the 
cough  by  narcotics,  as  it  is  feared  this  procedure  may  precipitate 
pneumonia.  For  nervous  symptoms  opium  used  cautiously  for 
a  day  may  serve  a  good  turn,  especially  Dover's  powder.  Alco- 
hol is  a  useful  remedy,  tranquillizing  and  relaxing  the  cutaneous 
blood-vessels.  When  the  glandular  enlargements  are  consider- 
able, creasote  is  recommended,  and  also,  internally,  preparations 
of  iodin,  especially  the  syrup  of  hydriodic  acid.  If  the  cough 
continues,  an  excellent  way  to  expedite  its  going  at  the  end  of  a 
week  or  two  is  to  administer  a  full  dose  of  castor  oil,  which  alone 
may  be  sufficient ;  or  if  this  fails,  full  doses  of  quinin  for  a  day 
or  two  will  often  bring  about  the  desired  result.  Many  cases  of 
bronchitis  need  no  expectorant  remedies,  and  do  better  under 
the  use  of  belladonna  or  hyoscyamus  and  their  derivatives.  Our 


CHRONIC    BRONCHITIS.  457 

custom  is  to  employ  a  tonic  from  the  start  containing  strychnin 
in  pretty  full  dose,  along  with  belladonna  and  the  faithful  use  of 
vigorous  counterirritation  to  the  chest  twice  or  thrice  daily. 


CHRONIC   BRONCHITIS. 

Chronic  bronchitis  or  subacute  bronchial  catarrh  is  occasion- 
ally encountered  when  the  child  has  either  had  repeated  exposure 
and  recurrent  attacks  of  bronchitis  or  is  so  weakened  in  health 
as  to  be  unable  to  acquire  full  restoration  after  a  fresh  attack. 
Sometimes  it  is  not  possible  to  account  satisfactorily  for  the  con- 
dition, though  there  will  usually  be  a  history  of  many  rapidly 
following  attacks  of  acute  bronchitis  or  an  unusual  susceptibility. 
This  last  may  be  inherent  or  the  result  of  specific  disease,  as  per- 
tussis, measles,  or  diphtheria.  The  rachitic  child  is  peculiarly 
susceptible  to  bronchitis  and  irritative  cough  ;  also  members  of 
tubercular  families  or  the  so-called  scrofulous  children. 

The  symptoms  are  troublesome  cough,  expectoration,  moist 
or  dry  rales,  generally  in  both  lungs  (if  fine  rales,  they  are  in  the 
bases  usually),  absence  of  fever,  and  unimpaired  resonance  or, 
possibly,  emphysema. 

Diagnosis. — From  fibroid  phthisis  the  distinguishing  points 
are  absence  of  dullness  and  of  such  rales  as  point  to  dilatation 
of  bronchi  or  consolidation,  normal  vocal  fremitus  and  resonance, 
and  one  or  more  of  the  occasional  outpourings  of  offensive  smell- 
ing mucopus  which  accompany  fibrophthisis. 

Additional  Suggestions  as  to  Treatment  of  Bronchitis  and  its 
Complications. — Certain  authorities  recommend  bicarbonate  of 
soda,  ten  to  fifty  grains  a  day,  with  one  grain  of  ipecac  ;  ten  to 
fifteen  grains  of  ammonium  chlorid  a  day,  or  two  to  five  grains 
every  three  hours  ;  apomorphin,  in  older  children,  -3-5-5-  of  a  grain 
every  two  or  three  hours,  or  potassium  iodid  to  loosen  a  "  tight 
cough  "  ;  terpin  hydrate,  in  doses  of  ^  to  ^  grain,  frequently 
repeated,  especially  in  the  chronic  form  ;  also  terebene,  ten-  to 
twenty-drop  doses.  The  complication  of  asthma  is  benefited  by 
iodid  of  potassium,  increasing  doses  to  toxic  effects,  then  slowly 
decrease  and  stop.  Accumulated  mucus  may  demand  an  emetic  ; 
if  danger  of  suffocation  or  great  effusion,  frequent  changes  of 
position.  If  cyanosis  arises  and  the  voice  is  not  heard,  it  is  im- 
perative to  make  the  child  cry — slapping  with  a  wet  cloth, 
swinging  about,  faradic  current,  etc.  If  cough  is  irritating,  small 
doses  of  opium,  codein,  or  extract  hyoscyamus,  the  opiate  espe- 
cially, at  night.  Chlorid  of  ammonia  evaporated  on  a  hot  stove, 
turpentine  atomized,  and  compound  syrup  of  white  pine  are  useful 


458  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

expectorants  ;  compressed  air  and  oxygen  are  of  great  help  in 
dyspnea  and  during  tardy  convalescence. 

Complications  of  Bronchitis. — Pharyngeal  catarrh  is  a  fre- 
quent cause  of  aggravated  cough  and  demands  local  treatment, 
such  as  frequent  washings  with  nitrate  of  silver  (weak  solution), 
alkaline  antiseptic  spray,  extract  of  hamamelis,  or  applications 
of  iodin,  potassium  iodid,  and  glycerin  solutions,  tannic  acid  in 
glycerin,  or  menthol  camphorate  in  liquid  petrolatum. 

Fibrinons  Bronchitis. — A  false  membrane  may  be  formed,  re- 
sembling diphtheria  ;  use  inhalations  of  steam,  turpentine,  ben- 
zoin, lime-water,  chlorid  of  ammonia,  fumigations  of  calomel,  ten 
to  fifteen  grains  every  few  hours  under  a  tent.  Internally  give 
potassium  iodid,  large  doses. 

Asthma  occurs  along  with  or  following  bronchitis,  and  is  fre- 
quently due  to  peribronchitis  and  emphysema ;  hence  potassium 
iodid  is  indicated,  with  an  opiate  at  night.  Cleansing  the  nares 
is  useful,  and  it  is  well  always  to  remove  all  obstruction  or 
hypertrophies.  For  the  asthmatic  attacks  :  tincture  of  lobelia, 
two  or  three  drops ;  fluid  extract  quebracho  or  grindelia,  ^  to 
one  dram  of  each,  will  often  relieve  dyspnea  (Jacobi).  Fluid 
extract  euphorbia  pilulifera,  increasing  doses,  is  a  very  useful 
antispasmodic.  Night  cough  and  night  irritation  are  relieved  by 
bedtime  doses  of  bicarbonate  of  soda  or  carbonate  of  magnesia 
and  codein  and  hyoscyamus  or  laxatives  of  castor  oil  or  cascara. 

Emphysema  in  children  presents  an  easier  diagnosis  than  in 
adults  :  the  lung  tissues  are  more  elastic  ;  cellular  activity  of  the 
alveoli  is  more  active  and  more  easily  influenced  by  nutrition 
and  by  remedies,  respiratory  exercises,  and  blood  repair ;  to  in- 
duce sneezing  is  of  value.  Nebulized  expectorants  and  resinous 
preparations  are  useful. 

BRONCHIAL  ASTHMA. 

Bronchial  or  spasmodic  asthma  is  a  form  of  paroxysmal  dysp- 
nea along  with  wheezing  respiration  occurring  in  sharp  attacks  ; 
but  perfect  health  is  enjoyed  between  the  intervals.  It  occurs 
quite  frequently  in  childhood,  and  rather  oftener  in  the  upper 
than  in  the  lower  walks  of  life.  Most  writers  agree  that  it  is  a 
neurosis  resulting  from  disturbed  innervatiori  of  the  pneumogas- 
tric  or  its  ramifications  or  the  vasomotor  nerves,  and  causing  a 
spasm  of  the  muscles  of  the  air-passages.  Hay-fever  is  an 
affection  which  closely  resembles  bronchial  asthma  and  alternates 
with  it.  The  affection  seems  to  run  in  certain  families,  especially 
those  of  irritable  and  unstable  nervous  equilibrium,  and  exciting 


BRONCHIAL   ASTHMA.  459 

causes  are  only  operative  when  there  is  a  predisposition  to  the 
disease.  Oftentimes  no  definite  exciting  cause  can  be  demon- 
strated. The  respiratory  center  in  the  medulla  is  thought  by 
some  to  be  irritated  by  vitiated  blood  of  a  wide  variety  of  sepsis. 
Enlarged  bronchial  glands  pressing  upon  the  pneumogastric 
nerve  or  upon  the  bronchioles  accounts  for  many  cases.  Bron- 
chitis alone  or  in  an  emphysematous  lung  is  frequently  recog- 
nized as  an  exciting  cause.  Various  mechanical  irritants  to  the 
upper  respiratory  mucous  membrane,  as  the  air  of  certain  local- 
ities, dust  of  various  sorts,  palpable  or  impalpable  powders, 
odors,  as  of  flowers  or  of  hay,  the  effluvia  of  animals  or  decom- 
posing substances,  and  an  endless  variety  of  causes  of  most 
differing  kinds  are  competent  to  excite  an  attack.  Changes  in 
the  barometric  pressure  and  disturbances  of  the  stomach  are  the 
most  efficient  instrumental  causes.  Asthma  and  eczema  some- 
times coexist  or  alternate  with  each  other. 

The  pathology  of  bronchial  asthma  is  not  known  ;  there  are 
many  theories,  such  as  that  it  may  be  due  to  spasm  of  the  bron- 
chial muscles  ;  also  that  the  attack  is  due  to  the  swelling  of  the 
bronchial  mucous  membrane,  to  a  catarrh  of  the  bronchioles, 
etc.  Talma  says  that  the  phenomenon  is  a  spasm  of  the  larynx 
and  aditus,  rarely  a  spasm  of  the  constrictors  of  the  glottis,  and 
that  it  is  partly  under  voluntary  control,  which  should  be  culti- 
vated as  much  as  possible. 

Symptoms. — Asthmatic  attacks  usually  occur  without  warn- 
ing. In  some  there  are  slight  premonitions,  rather  vague  ;  in 
others  there  is  itching  of  the  skin,  copious  urination,  or  a  slight 
nasal  catarrh.  The  paroxysm  generally  comes  on  at  night,  the 
patient  being  awakened  by  distressing  dyspnea,  steadily  increas- 
ing, with  characteristic  wheezing  and  oppression  or  pain  of  the 
chest.  He  must  sit  up,  and  is  more  comfortable  holding  on  to 
objects,  with  shoulders  elevated  and  head  thrown  back,  to  give 
the  muscles  of  respiration  and  their  allies  the  utmost  play.  The 
face  becomes  anxious,  pallid,  and,  later,  cyanotic ;  the  skin  is 
moist,  and  respiration  is  loud  and  wheezing.  The  respirations 
are  rarely  much  increased  in  number  ;  speech  is  difficult  ;  the 
ribs  expand  but  little ;  inspiration  is  jerky  and  expiration  pro- 
longed and  laborious,  and  there  is  little  or  no  thoracic  expansion. 
The  pulse  is  rapid  and  thready,  there  is  no  elevation  of  tempera- 
ture, but  in  a  prolonged  attack  it  becomes  subnormal,  the  ex- 
tremities growing  cold  and  clammy,  the  face  livid.  After  the 
paroxysm  there  is  usually  much  exhaustion,  and  the  patient 
sleeps.  On  awakening  there  is  little  left  except  muscular  sore- 
ness, and  the  return  to  usual  health  is  prompt.  Percussion  dur- 


460  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

ing  the  paroxysm  shows  hyperresonance,  and  there  is  heard  some 
diminution  or  prolongation  of  the  vesicular  murmur.  Toward 
the  close  of  the  attack  moist  rales  are  distinguished,  and  piping, 
wheezing,  and  cooing  sounds. 

The  prognosis  in  young  subjects  is  good  ;  especially  is  improve- 
ment marked  in  some  cases  about  the  time  of  puberty,  and  if 
there  be  no  serious  complication  or  grave  underlying  disorder. 

The  diagnosis  should  not  be  difficult,  but  bronchial  asthma 
may  be  confused  with  obstruction  of  the  upper  air-passages, 
foreign  bodies,  croup,  edema  of  the  glottis,  suffocative  urticaria, 
new  growths  in  the  larynx,  tracheal  stenosis,  pulmonary  edema, 
pleuritic  effusion,  uremia,  and  cardiac  disease.  Bearing  in  mind 
the  absence  of  elevation  of  temperature  will  enable  one  to  dis- 
tinguish asthma  from  the  inflammatory  affections.  Emphysema 
and  asthma  frequently  coexist,  and  the  one  may  superinduce  the 
other.  Cardiac  asthma  is  rare  in  children. 

Treatment. — Most  sufferers  from  bronchial  asthma  are  below 
par  in  health  in  some  direction,  and  these  factors  need  special 
reparative  treatment  as  well  as  specific  medication.  Some  suffer- 
ers from  asthma,  however,  are  of  magnificent  physique,  as  evi- 
denced by  two  personal  friends  of  the  authors,  who  have  made 
themselves  famous  on  two  continents  as  monumental  specimens 
of  vigor.  The  treatment  divides  itself  into  the  special  medication 
directed  to  the  prevention  of  the  paroxysm  and  the  use  of  reme- 
dies to  relieve  the  suffocative  attacks.  It  may  as  well  be  frankly 
stated  that  there  has  been  very  scanty  success  in  the  treatment  of 
this  disorder.  This  may  be  because  physicians,  as  a  rule,  do  not 
give  it  sufficient  attention,  and  the  most  conspicuous  instances 
of  relief  are  occasionally  seen  at  the  hands  of  certain  quacks  or 
of  physicians  who  keep  secret  the  means  and  manner  of  their 
work.  It  is  quite  impossible  to  enumerate  here  the  wearisome 
array  of  remedies  and  measures  offered  for  the  relief  of  asthma, 
especially  if  we  include,  also,  disturbances  from  that  disease, 
known  as  hay-fever,  rose  cold,  and  the  like.  Wherever  there 
can  be  discovered  exciting  causes,  the  most  obvious  of  which  are 
nasopharyngeal  obstructions,  these  must  be  removed,  and  thor- 
oughly ;  hypertrophied  turbinated  bodies,  or  lingual  or  pharyngeal 
tonsils,  adenoid  growths,  nasal  polypi,  and  catarrh  of  any  part 
of  the  respiratory  tract  demand  attention.  Climatic  and  domestic 
conditions  must  be  revised ;  diet  should  be  modified  and,  as  a 
rule,  lessened.  Hygiene  ;  out-of-door  life  ;  cold  sponging,  always 
preceded  by  a  dry  rub ;  change  of  climate  here  and  there,  in  the 
choice  of  which  there  is  almost  no  special  rule  ;  the  use  of  certain 
tonics  (cod-liver  oil  and  iron  are  lauded)  and  of  various  altera- 


BRONCHIAL    ASTHMA.  461 

tives  ;  long  courses  of  arsenic  and  of  various  sorts  of  alkalies 
(because  uricacidemia  is  so  often  the  chief  fault) — produce  a  fair 
proportion  of  cures.  The  best  single  remedy  is  potassium  iodid, 
and  perhaps  the  most  satisfactory  plan  of  treatment,  certainly  in 
our  experience,  is  the  following  :  Put  the  sufferer  to  bed,  or  limit 
his  activities  as  much  as  possible  ;  feed  upon  an  absolute  diet  of 
skimmed  milk,  with  peptonizing  and  antifermentative  measures  if 
necessary  ;  keep  the  bowels  open,  preferably  with  salines  (mixed 
ones  are  better  than  single,  like  Apenta  water),  and  administer 
potassium  iodid  in  rising  doses,  one  drop  of  a  saturated  solution 
extra  each  day,  until  full  toxic  symptoms  are  produced  ;  then 
slowly  reduce  in  the  same  order  to  the  point  of  tolerance,  and 
keep  at  that  for  about  a  month  ;  then  slowly  lessen  until  none  is 
taken.  In  so  complicated  a  malady  as  bronchial  asthma,  with 
its  peculiar  features,  the  vigorous  health  so  often  seen,  which  is 
suddenly  and  overwhelmingly  paralyzed  by  intensity  of  distress, 
argues  either  for  a  profound  neurosis  or  for  diathetic  conditions 
as  yet  not  understood,  but  for  which  it  is  reasonable  to  hope  and 
expect  to  discover  a  controlling  remedy  sooner  or  later.  The 
relief  of  the  paroxysm  is  also  not  to  be  predicted  ;  some  simple 
thing  may  accomplish  this  perfectly  or  powerful  medicines  may 
be  demanded.  Morphin,  administered  under  the  skin,  especially 
along  with  a  little  atropin,  promptly  relieves  most  adult  cases, 
and  may  be  given,  with  the  utmost  caution,  to  children  ;  but  its 
use  is,  of  course,  not  to  be  encouraged.  The  inhalation  of  chloro- 
form offers  prompt  and  temporaiy  relief.  Chloral  hydrate,  given 
by  the  mouth  or  rectum,  is  better  and  more  lasting.  Nitrite  of 
amyl  or  iodid  of  ethyl  inhaled,  or  nitroglycerin  given  by  the 
mouth,  pilocarpin  under  the  skin,  the  use  of  many  pungent 
smokes,  as  of  stramonium,  relieve  some  cases.  Perhaps  the  best- 
known  remedy  is  the  fumes  of  niter  paper ;  and  safe  enough  it  is, 
especially  if  administered  under  a  tent.  There  are  various  combi- 
nations put  up  in  the  form  of  cigarettes,  the  materials  of  which 
are  modestly  concealed  ;  or  powdery  substances  to  be  burned, 
sold  in  the  shops  as  infallible  remedies,  are  quite  useful.  Tobacco 
is  advocated,  but  is  depressing  to  children.  The  nitrites  are 
praised,  but  are  disappointing ;  so  are  grindelia  and  quebracho. 
The  best,  perhaps,  is  the  fluid  extract  of  euphorbia  pillulifera  in 
increasing  doses.  Talma  claims  that  patients  should  be  syste- 
matically taught  respiratory  gymnastics,  learning  to  breathe 
slowly  and  deeply.  We  can  also  assert  that  this  treatment  has 
done  much  for  those  under  our  control. 


462  DISEASES    OF    THE    RESPIRATORY    ORGANS. 


PULMONARY  EMPHYSEMA. 

Pulmonary  emphysema  is  a  condition  of  the  lung  in  which  air 
to  an  abnormal  extent  accumulates  within  it.  The  interstitial 
form,  known  also  as  the  extravesicular,  gives  rise  to  no  untoward 
symptoms,  as  a  rule.  The  vesicular  variety,  also  known  as 
alveolar  emphysema,  is  of  much  more  importance  if  the  process 
be  extensive,  but  is  extremely  rare  in  children  under  ten  years 
of  age.  This  is  again  divided  into  two  varieties  :  (i)  Compensa- 
tory emphysema,  wherein  the  vesicles  of  one  portion  of  the  lung 
are  abnormally  distended  in  consequence  of  the  disablement  or 
insufficient  expansion  of  some  other  part  of  that  organ.  This 
form  of  emphysema  is  occasionally  seen  in  young  children,  the 
causes  being  predisposition,  enfeeblement,  lowered  nutrition,  and 
locally  mechanical  obstruction,  which  produces  increased  vesicu- 
lar pressure.  Excessive  coughing  in  pertussis  produces  violent 
respiratory  efforts,  inducing  air-bubbles  to  escape  into  the  in- 
terlobular  tissue,  as  well  as  hyperdistention  of  the  alveoli.  In 
most  cases,  however,  complicating  acute  bronchitis  and  pertussis 
the  emphysema  is  but  temporary,  and  small  structural  change  is 
left.  (2)  Substantive  emphysema  is  a  chronic  and  sca'rcely  cur- 
able malady,  characterized  by  abnormal  distention  of  the  air  vesi- 
cles along  with  structural  changes  in  their  walls.  It  is  almost 
never  seen  in  children  under  ten  years  of  age,  but  is  more  fre- 
quently encountered  during  adolescence.  It  would  seem  to  be 
due  in  part  to  hereditary  tendency.  Bronchial  catarrh  inducing 
swollen  mucous  membranes,  and  much  pressure  in  the  bronchi- 
oles due  to  sticky  mucus,  induce  topical  collapse,  and  the 
neighboring  lobules  endeavor  to  do  double  work  and  become 
hyperdistended. 

Again,  during  enforced  respiratory  efforts  with  a  closed  glottis, 
as  in  violent  paroxysmal  coughing,  the  air  is  driven  back  and 
becomes  lodged  in  the  less  resisting  areas,  as  the  apices  and 
anterior  borders  of  the  lungs.  In  any  event  there  needs  to  be 
some  inherent  feebleness  or  degenerative  change  to  account  for 
the  anatomic  alteration.  This  may  be  a  chronic  inflammation,  a 
pneumonitis  attended  with  the  production  of  fibrinous  tissue, 
along  with  an  atrophy  of  the  normal  parenchyma.  The  post- 
mortem changes  are  much  the  same  as  in  the  emphysema  of 
adults.  There  is  usually  some  hypertrophy  of  the  right  ventri- 
cle of  the  heart  and  perhaps  secondary  dilatation.  The  symp- 
toms of  emphysema  in  young  children  are  oftentimes  negative, 
and  when  present,  are  like,  but  milder  than,  those  in  adults. 
Dyspnea  is  one  of  the  most  common  symptoms,  at  first  only 


ACUTE    BROXCHOPXEUMOXIA.  463 

noticed  upon  exertion,  and  later  more  severe  upon  slight  catarrhal 
disturbances  of  either  the  nose  or  the  nasopharynx,  the  bronchi, 
or  digestive  organs.  Cough  is  readily  excited,  especially  in  winter, 
and  asthma  often  arises.  Children  rarely  exhibit  the  barrel- 
shaped  chest  of  emphysema,  but  they  do  sometimes  show  an 
increased  depth  anteroposteriorly  and  rigidity.  Percussion  gives 
few  signs  of  value  ;  the  thoracic  walls  of  children  being  so  elas- 
tic and  the  organs  small,  transmission  of  resonance  is  favored 
from  other  parts.  Auscultation  reveals  a  low-pitched  respiratory 
murmur  with  prolonged  expiration  ;  the  second  sound  of  the 
heart  may  be  accentuated.  Recovery  may  be  looked  for  if  the 
disturbance  has  not  continued  too  long.  Emphysema  itself 
does  not  imperil  life  except  as  a  complicating  factor  in  other  dis- 
eases. 

Treatment. — The  treatment  is  mainly  prophylactic  ;  exciting 
causes  should  be  guarded  against  and  receive  prolonged  treatment. 
Attention  to  the  skin  by  cool  bathings  and  thorough  rubbing 
must  be  faithfully  and  continuously  given,  and  woolen  underwear 
worn.  The  digestive  organs  must  be  guarded  from  disturbance 
with  unusual  faithfulness.  Many  tonics  are  of  value,  of  which  iron 
has  a  suitable  place,  especially  in  the  form  of  Basham's  mixture. 
Nux  vomica  is  of  some  efficacy,  and  arsenic  more  so.  In  the 
chronic  bronchitis  which  so  frequently  coexists  iodid  of  potas- 
sium is  of  special  value.  Next  come  the  resinous  preparations, 
then  terebene  and  guaiacol.  Cod-liver  oil  is  a  reliable  tonic. 

ACUTE   BRONCHOPNEUMONIA. 

Bronchopneumonia — also  called  catarrhal  pneumonia,  lobular 
pneumonia,  capillary  bronchitis — is  an  inflammatory  disease  of 
the  terminal  bronchioles  and  pulmonary  air  vesicles,  affecting 
the  lobules  in  scattered  areas.  The  disorder  is  in  the  main  a 
catarrhal  inflammation  of  the  bronchioles  and  air-sacs,  although 
the  peribronchial  and  interventricular  tissues  are  also  involved. 
The  disease  often  proves  fatal  in  a  few  days,  or  it  may  linger  in 
a  chronic  form,  leading  to  secondaiy  changes  or  inducing  a  ten- 
dency to  tuberculous  infection. 

Causes. — The  primary  cause  is  usually  bronchitis,  either  the 
simple  catarrhal  form  or  that  which  accompanies  or  follows  infec- 
tious processes,  especially  measles,  whooping  cough,  diphtheria, 
or  tuberculosis.  Bronchopneumonia  is  in  nearly  all  cases  a  sec- 
ondary disease  ;  it  may  arise  as  a  primary  disease,  or  from  an 
untraceable  cause,  or  as  the  result  of  irritants,  mechanical  or 
gaseous,  entering  through  the  mouth,  nose,  or  respiratory  pas- 


464  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

sages.  In  the  bronchopneumonia  of  diphtheria  the  streptococcus 
is  the  usual  cause.  In  the  new-born  it  may  result  from  inhala- 
tions of  the  maternal  secretions  during  birth.  In  many  cases 
the  specific  cause  is  the  pneumococcus,  the  tubercle  bacillus, 
or  in  certain  instances  the  staphylococcus  aureus  and  albus 
or  streptococcus  pyogenes.  Secondary  cases  are  usually  due  to 
a  mixed  infection.  Most  fatal  cases  occur  under  two  years  of 
age,  especially  during  primary  dentition.  Pneumonias  stand 
next  to  diarrheas  as  a  cause  of  infantile  mortality,  and  the  lobu- 
lar  is  much  more  common  than  the  lobar  form.  Infants  show  a 
marked  tendency  to  catarrhal  processes.  Depraved  vitality  is  a 
powerful  predisposing  cause,  the  result  of  unwholesome  envir- 
onment and  diet  and  improper  care.  Especially  is  this  notice- 
able during  the  prevalence  of  epidemics  of  measles,  diphtheria, 
and  whooping-cough,  during  convalescence  from  which  sufficient 
care  is  too  rarely  exercised.  Season  has  much  to  do  with  the 
prevalence  of  this  disease,  it  being  by  far  the  more  frequent 
during  the  winter  and  spring,  and  especially  if  the  weather  be 
changeable  from  wet  to  dry.  Steady  cold  is  rather  favorable  to 
immunity  from  catarrhal  pneumonia,  but  during  damp  summers 
it  is  liable  to  prevail. 

Pathology. — The  essential  lesion  in  bronchopneumonia  is  an 
inflammation  of  the  walls  of  the  terminal  bronchi,  bronchioles, 
and  the  adjacent  alveoli,  with  the  rapid  casting  off  of  epithelial 
cells,  one  after  another,  along  with  a  few  leukocytes  or  red  cor- 
puscles accumulating  within.  As  the  process  continues  there 
is  an  increase  in  cellular  desquamation,  with  outpouring  of 
mucus,  filling  up  the  tubes  and  air  vesicles  ;  thus  centers  of  con- 
solidation are  formed  in  different  parts  of  the  lung,  at  times  only 
attacking  small  portions,  and  again  invading  large  areas  irregu- 
larly. Both  lungs  are  usually  attacked,  sometimes  so  exten- 
sively as  to  involve  a  whole  lobe.  Bronchopneumonia  develops 
by  the  regular  invasion  of  successive  portions  of  the  lung,  and 
resolution  takes  place  in  the  same  gradual  manner.  The  mot- 
tled appearance  seen  on  inspecting  an  infected  lung  is  due  to 
areas  of  red  and  gray  hepatization  in  close  proximity.  Absorp- 
tion takes  place  more  readily  of  the  fibrinous  exudate  than  of  the 
cellular  elements  :  and  hence  in  bronchopneumonia,  where  the 
inflammatory  products  are  mostly  cellular,  they  are  more  slowly 
resolved  than  in  lobar  pneumonia,  in  which  they  are  mostly  fibrin- 
ous. The  process  begins  in  the  terminal  bronchi  and  extends 
into  the  bronchioles  and  air-sacs,  either  by  inflammation,  follow- 
ing the  epithelial  lining,  or  mechanically,  by  violent  inspiratoiy 
efforts  induced  by  coughing.  Thus  the  smaller  tubes  become 


ACUTE    BRONCHOPNEUMONIA.  465 

plugged  up,  producing  atelectasis,  even  where  the  act  of  expira- 
tion forces  the  air  out  of  the  cell,  and  inspiration  being  a  weaker 
act,  they  fail  to  become  or  are  only  slowly  refilled.  Once  the 
vesicles  become  collapsed  congestion  takes  place,  which  is  also 
partly  mechanical,  inflammation  results,  and  the  temperature 
goes  up.  Parts  of  the  lungs  which  are  not  hepatized  are  con- 
gested and  edematous,  and  the  air-spaces  in  the  alveoli  are 
encroached  upon  by  the  congested  blood-vessels  and  epithelium. 

On  microscopic  examination  the  bronchioles  will  be  found  filled 
with  an  exudate  containing  leukocytes  and  epithelial  cells  ;  occa- 
sionally, also,  blood-corpuscles.  The  alveoli  in  the  immediate 
neighborhood  of  the  affected  bronchus  will  be  more  completely 
filled  with  the  exudate  than  the  outlying  ones.  The  capillaries 
in  the  walls  of  the  bronchi  are  somewhat  distended,  and  the 
general  appearances  of  an  interstitial  inflammation  are  present. 

These  areas  of  collapse  are  mostly  symmetric,  occurring  in 
the  posterior  borders  of  both  lower  lobes,  and  sometimes  in  the 
upper  ones,  and  may  arise  during  the  acute  stage  or  when  the 
pneumonic  process  is  more  definitely  established.  There  are  no 
clearly  marked  stages  in  bronchopneumonia  as  in  lobar  pneu- 
monia, and  all  of  them  may  appear  in  different  areas  of  the  same 
lung.  Nearby  these  zones  of  congestion  the  bronchi  frequently 
become  dilated,  owing  to  the  weakened  condition  of  the  bronchial 
\valls  ;  yet  this  condition  is  liable  to  disappear  entirely  upon 
recovery.  Emphysema  frequently  arises  in  the  course  of  bron- 
chopneumonia, usually  vesicular,  and  more  commonly  in  the 
upper  lobes,  but  also  may  be  wide-spread,  and  is  more  common 
after  whooping-cough.  There  may  be  interstitial  emphysema 
also,  caused  by  the  rupture  of  air  vesicles  lifting  the  pleura  or 
extending  between  the  lobules.  Bronchopneumonia  may  persist, 
the  proliferative  cells  taking  part  in  the  formation  of  new  connec- 
tive tissue,  causing  persistent  thickening.  This  occurs  especially 
after  other  than  first  attacks.  The  walls  of  the  bronchi  and  the  peri- 
bronchitic  tissue  are  at  times  subject  to  a  persistent  thickening 
and  fibrinous  formation,  producing  a  chronic  bronchopneumonia. 
The  cicatricial  tissue  surrounding  the  bronchi  causes  an  increased 
dilatation  in  the  walls  already  weakened,  and  there  follows  saccu- 
lar  as  well  as  fusiform  dilatation. 

The  macroscopic  appearances  usually  show  a  tendency  to 
lobular  limitation,  these  lobules  being  raised  somewhat  from  the 
surface  and  exhibiting  alternations  of  dark-red  or  grayish  color. 
Sometimes  a  whole  lobe  may  be  affected,  and  then  it  is  very  like 
the  appearance  of  croupous  pneumonia.  Next  to  the  consolidated 
lobules  there  is  sometimes  seen  emphysema,  the  one  overlying  the 
30 


466  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

other.  On  the  lung  being  cut,  the  various  lesions  are  seen  most 
beautifully,  areas  of  atelectasis  and  of  peribronchitic  congestion 
adjoining  the  smaller  bronchi  (from  some  of  which  issues  mucus 
or  mucopus)  and  emphysematous  patches.  The  air  vesicles  are 
themselves  sometimes  inflamed  and  found  filled  with  red  blood- 
cells.  In  the  very  acute  cases  extravasation  of  blood  occurs  into 
the  alveoli  just  beneath  the  pleura.  Adjoining  the  consolidated 
areas  there  is  usually  pleurisy,  especially  over  considerable  areas 
of  consolidation,  binding  the  lung  to  the  chest-walls.  There  is 
also  occasionally  a  moderate  amount  of  exudation  into  the  pleural 
cavity. 

The  causes  of  death  in  pneumonia  of  children  are  (i)  ex- 
haustion, (2)  acute  toxemias,  and  (3)  complications.  Exhaustion 
is  the  most  common  and  is  to  be  met  by  sedulous  attention  to 
hygiene  and  diet.  Nursing  infants  should  be  spared  overofficious 
attention.  The  complications  are  most  liable  to  cause  death, 
except  the  pleurisies. 

Symptoms. — Bronchopneumonia,  as  has  been  said,  is  almost 
always  a  secondary  disease,  and  it  is  liable  to  arise  in  the  course 
of  a  bronchitis  or  of  some  one  of  the  contagious  diseases — 
measles,  scarlatina,  whooping-cough,  influenza,  and  -diphtheria 
especially.  There  is  then  to  be  recognized  some  increment 
of  fever-  in  the  rate  of  pulse,  and  especially  a  difficulty  in 
breathing.  The  fever  is  at  its  height  in  from  three  to  five  days, 
and  usually  quite  irregular  in  course,  above  102°  up  to  104°  or 
105°  F.,  or  in  rare  cases  even  higher.  The  height  of  this 
becomes  a  fair  index  to  the  virulence  of  the  disease.  Deaths 
with  low  temperature  occur  only  in  very  feeble  children.  The  rise 
and  fall  on  the  temperature-chart  is  gradual,  and  feverishness  per- 
sists for  a  considerable  time.  The  pulse  becomes  greatly  increased 
(125  to  150),  and  the  ratio  between  pulse  and  respiration  is  from 
one  to  two,  or  even  less.  The  cough  is  usually  short  and 
hacking,  less  distressful  than  in  a  severe  bronchitis,  and  more  con- 
sciously controlled.  It  is  more  pronounced,  constant,  and  dis- 
tressing in  lobar  pneumonia.  The  cough  is  a  valuable  index  of 
the  vigor  of  the  child  and  the  progress  of  the  case.  When  this 
becomes  feeble,  it  is  a  sign  of  respiratory  and  other  organic 
failure.  The  pain  felt  is  less  in  front,  as  in  bronchitis,  and  more 
in  the  side.  The  alae  of  the  nose  are  seen  to  dilate,  especially 
in  little  children.  When  atelectasis  takes  place,  the  dyspnea 
becomes  more  marked  and  the  expiration  "  grunting  "  ;  the  skin 
becomes  livid  and  dusky,  and,  as  we  have  often  had  occasion  to 
remark,  the  characteristic  symptom  here  is  increased  relaxation 
and  leakiness  of  the  skin.  As  the  symptoms  become  severe  the 


ACUTE    BROXCHOPNEUMONIA.  467 

child  remains  more  and  more  quiet,  holding  its  head  well  back 
and  supporting  itself  by  the  hands  ;  it  is  a  characteristic  feature 
that  the  worse  the  malady,  the  more  submissive  is  the  child. 
Expectoration  is  liable  to  be  mucopurulent,  but  infants  and  chil- 
dren under  six  or  seven  years  swallow  and  conceal  this.  Appe- 
tite is  generally  lost,  but  thirst  is  excessive.  The  suckling  of 
infants  is  difficult  and  incomplete,  on  account  of  the  dyspnea. 
Strength  is  rapidly  lost,  and  somnolence  is  a  very  evil  sign. 
Vomiting  may  occur  at  the  outset,  and  diarrhea  is  a  bad  compli- 
cation. Irregular  fever  with  high  pulse-rate  indicates  a  protracted 
course,  and  possibly  chronicity.  The  heart  must  be  carefully 
watched  ;  a  feeble  first  sound  is  of  gloomy  import,  though  death 
is  more  likely  to  result  from  respiratory  than  cardiac  failure.  In 
the  beginning  there  are  the  usual  signs  of  bronchitis — first  dry 
and  later  moist  rales,  without  dullness.  As  areas  of  congestion 
arise  dullness  on  percussion  may  be  recognized  ;  but  it  is  diffi- 
cult to  elicit  unless  pronounced,  and  then  only  on  using  the 
lightest  percussion.  These  congested  areas  are  best  recognized 
by  moving  a  stethoscope  here  and  there  while  the  child  cries, 
and  locating  by  increased  vocal  fremitus  and  resonance.  If  a 
lobe  of  the  lung  be  extensively  affected,  the  signs  are  more  pro- 
nounced, but  ordinarily  it  will  be  necessary  to  explore  the  two 
sides  symmetrically  and  estimate  by  these  lesser  sounds.  More- 
over, the  symptoms  vary  from  day  to  day,  almost  from  hour  to 
hour.  Characteristic  symptoms  are  oftentimes  best  heard  high 
up  in  the  axilla.  When  atelectasis  or  emphysema  is  present, 
there  is  a  great  variety  of  changes  in  the  symptoms,  which  may 
occur  swiftly.  There  are  practically  no  characteristic  signs  in 
bronchopneumonia,  but  if  in  addition  to  the  rales  of  bronchitis 
there  is  heard  subcrepitation,  with  harsh  or  blowing  breathing 
and  impaired  resonance  in  the  lower  part  of  the  lungs  posteriorly, 
and  along  with  these  pronounced  and  increasing  prostration,  we 
may  regard  the  disease  as  clearly  evidenced. 

Complications  and  Sequelae. — Pulmonary  collapse  is  less  a 
complication  than  a  feature  to  be  expected.  Sometimes  it  is  so 
extreme  as  to  warrant  the  use  of  the  old  term  "  sufibcative 
catarrh."  Pleurisy  is  a  frequent  but  only  rarely  a  troublesome 
complication.  The  most  serious  sequela  is  tuberculosis.  Broncho- 
pneumonia  renders  a  person  peculiarly  susceptible  to  this  poison. 
Meningeal  symptoms  sometimes  arise  toward  the  end  of  the  dis- 
order, probably  due  to  hyperemia  of  the  meninges  or  to  toxemia. 
Chronic  or  continued  pneumonic  process  is  a  serious  feature  not 
uncommon.  Cases  may  go  on  to  rapid  or  slow  resolution  and 
yet  recovery  be  complete  and  thorough.  A  form  of  continued 


468  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

catarrh  of  the  alveolae  is  described  by  Douglas  Powell,  usually 
seen  in  the  apices  of  the  lungs.  This  begins  as  a  proliferation 
of  the  alveolar  epithelium.  In  the  milder  cases  the  inflammatory 
products  are  expectorated,  leaving  the  alveolar  walls  undamaged  ; 
when  the  inflammatory  process  is  greater,  the  proliferated  epi- 
thelium and  the  leukocytes  are  sufficient  to  block  the  alveoli 
completely.  The  exudate  undergoes  degeneration,  and  may  be 
partially  absorbed  and  partly  expectorated,  but  the  alveolar 
walls  have  been  damaged  and  collapse  results  from  their  agglu- 
tination. The  inspissated  products  may  remain  a  long  time,  or 
the  fibrous  stroma  may  become  involved  and  a  hyperplasia  result, 
and  ultimately  a  fibrosis  takes  place  of  the  affected  area.  Such 
cases  may  linger  long  in  the  condition  or  fall  into  serious  states, 
or  die  of  exhaustion  or  some  intercurrent  malady,  especially 
tuberculosis.  Other  forms  of  bronchopneumonia  suffer  relapses 
or  recurrences  and  result  in  a  chronic  interstitial  pneumonia. 

Associated  lesions  of  the  lung  are  enlarged  bronchial  glands, 
more  or  less  emphysema  in  almost  all  cases,  gangrene  rarely,  and 
abscess  more  frequently  than  is  suspected. 

Diagnosis. — It  is  important  to  examine  every  case, of  bronchi- 
tis critically  for  the  intercurrence  of  a  possible  pneumonia,  also  in 
the  infectious  diseases.  This  may  be  recognized  by  sudden  increase 
of  fever,  acceleration  of  pulse  and  respiration,  fine  subcrepitant 
rales,  blowing  breathing,  and  small  areas  of  percussion  dullness. 
Catarrhal  pneumonia  may  exist  without  signs  of  consolidation.  If 
the  disease  is  first  seen  in  a  well-developed  state,  it  may  readily 
be  confused  with  croupous  pneumonia,  but  scattered  areas  of  dull- 
ness in  the  opposite  lung  will  help  to  distinguish  it,  along  with  the 
history  of  the  case  and  its  gradual  onset.  Plastic  pleurisy  usually 
accompanies  bronchopneumonia  and  confuses  the  physical  signs. 
When  gastro-intestinal  disorders  or  nervous  symptoms  are  marked 
features,  the  pneumonia  may  escape  attention  unless  searched  for. 
Here  the  changed  respiration  and  pulse-rate  should  be  an  indi- 
cation. 

The  prognosis  is  always  bad,  the  average  mortality  being 
nearly  50  per  cent,  under  five  years  of  age,  and  less  over  that 
period.  In  private  practice  (Holt)  the  mortality  is  from  loto  30 
per  cent.  The  cases  which  follow  whooping-cough  are  most 
serious  ;  also  those  complicated  by  previous  marked  debility. 
Duration  is  usually  from  two  to  three  weeks  ;  mild  cases  may 
terminate  in  a  week.  The  symptoms  to  be  considered  in  making 
a  prognosis  are  the  height  and  course  of  the  temperature,  the 
occurrence  or  absence  of  neurotic  phenomena,  the  state  of  the 
digestive  organs,  the  presence  of  cyanosis,  and  the  extent  and 


CHRONIC    BRONCHOPNEUMONIA.  469 

character  of  the  diseased  areas,  and  also  whether  or  not  the  pro- 
cess follows  an  infectious  disease. 

Treatment. — The  chief  element  of  treatment  is  prevention, 
bronchopneumonia  being  essentially  a  secondary  disease  and  con- 
trollable in  most  instances  by  proper  care.  The  measures  used 
should  be  early  applied.  Any  case  of  bronchitis  may  be  com- 
plicated by  more  or  less  pneumonia.  (For  treatment  see  separate 
article  on  Treatment  of  Pneumonia.) 

CHRONIC    BRONCHOPNEUMONIA. 

Chronic  bronchopneumonia,  also  called  fibroid  phthisis,  is  a 
condition  of  the  connective-tissue  framework  of  the  lungs  follow- 
ing upon  other  diseases.  The  condition  is  known  also  as  chronic 
or  interstitial  pneumonia,  cirrhosis,  or  fibroid  induration  of  the 
lungs,  and  is  usually  accompanied  by  dilatation  of  the  bronchi.  It 
is  generally  of  one  side,  protracted  in  its  course,  and  is  charac- 
terized by  a  change  from  the  normal  pulmonary  tissue  to  the  ex- 
cessive formation  of  connective  tissue,  and  is  often  associated  with 
or  followed  by  tuberculosis.  It  is  held  by  some  that  fibroid 
phthisis  begins  as  a  tuberculosis  in  all  instances.  It  is  certainly 
proved  that  many  inflammations  of  serous  membranes  aforetime 
ascribed  to  exposure  to  cold  are  really  tubercular.  This  is  espe- 
cially true  of  the  pleura.  The  affection  is  rare  in  children,  they 
usually  exhibiting  a  more  active  process  during  an  inflammation, 
with  a  larger  power  of  complete  repair.  When  seen  in  adults,  the 
origin  may  frequently  be  traced  to  childhood.  A  simple  bron- 
chitis may  set  up  changes  which  result  in  an  overgrowth  of  the 
interstitial  connective  tissue.  (See  Chronic  Bronchitis.)  It  is 
exceedingly  uncommon  in  children  to  find  an  abundant  connec- 
tive-tissue growth  the  result  of  an  ulcerating  tubercular  process 
in  the  lung,  although  it  is  possible.  The  usual  origin  of  fibroid 
phthisis  in  children  is  in  the  results  of  pneumonia  and  broncho- 
pneumonia,  especially  the  latter.  Bronchiectasis,  a  cylindric 
dilatation  of  the  bronchi,  is  also  frequently  present,  due  to  exces- 
sive coughing.  An  entire  lobe  may  be  affected,  but  usually  only 
a  portion  of  a  lobe  or  areas  in  the  lung  or  the  walls  of  the 
bronchi  may  be  thickened. 

Pathology. — The  changes  in  the  lung  are  usually  upon  one 
side  and  in  the  lower  lobes.  The  parenchyma  of  the  lung  ap- 
pears destroyed  and  replaced  by  connective  tissue.  There  is 
usually  peribronchitic  thickening  and  also  bronchial  dilatation, 
producing  cavities  of  varying  sizes.  Cavities  may  also  be  formed 
through  ulcerative  change,  particularly  where  secretions  are  re- 


4/O  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

tained  and  become  decomposed.  Tubercle  bacilli,  active  or 
latent,  may  be  found  in  the  tissues  or  secretions  or  locked  up  in 
the  connective  tissue.  The  lung  usually  suffers  some  diminution 
in  size,  which  is  shown  upon  inspection.  The  pleura  is  generally 
affected,  and  adhesions  are  liable  to  be  particularly  dense.  The 
sound  lung  exhibits  compensatory  hypertrophy  and  often  em- 
physema. The  heart  rarely  escapes  displacement,  and  the  cavi- 
ties suffer  change  because  of  the  increased  resistance  in  the  pul- 
monary circulation.  A  common  result  of  pleural  inflammation 
is  adhesive  pericarditis  ;  this  may  be  found  here,  as  well  as  a  gen- 
eral venous  stasis. 

Symptoms. — There  are  always  in  chronic  bronchopneumonia 
cough  and  expectoration,  though  the  latter  varies  considerably  in 
amount  at  different  periods.  When  cavities  exist,  the  sputum 
may  separate  into  three  layers  of  froth,  serum,  and  pus  ;  it  is 
often  of  a  most  offensive  odor.  If  tubercle  bacilli  be  found,  they 
may  betoken  a  recent  infection  from  outside  or  a  manifestation 
of  latency.  Elastic  fibers  will  be  shown  if  ulceration  is  present. 
Hemoptysis  occurs,  usually  of  moderate  amount ;  but  if  a  fair- 
sized  vessel  be  affected,  danger  results,  or  possibly  death.  Even 
in  favorable  cases  dyspnea  arises  upon  exertion,  or  even,  in  worse 
ones,  while  the  patient  is  at  rest.  Fever  and  its  effects  are  absent 
or  occur  only  intermittently.  Should  it  arise,  it  is  a  symptom  of 
some  secondary  complication.  Nutrition  suffers  little,  and  the 
general  health  is  fair.  That  infallible  sign  of  chronicity,  clubbing 
of  the  fingers  and  toes,  is  more  constantly  seen  in  interstitial 
pneumonia  than  in  any  other  condition,  except,  perhaps,  con- 
genital heart  affections.  The  physical  signs  are  similar  to  those 
of  chronic  tuberculosis.  Certain  signs  are,  however,  distinctive 
of  this  malady.  The  respiratory  murmur  is  much  impaired  unless 
there  is  bronchiectasis,  when  the  breathing  is  distinctly  bronchial. 
The  two  sides  of  the  chest  show  a  notable  difference  in  shape, 
mobility,  and  size,  especially  when  pleural  changes  are  extensive. 
Retraction  is  more  common  if  the  apex  is  affected.  Exploration 
of  the  chest  may  reveal  areas  of  consolidation,  retained  secretion, 
or  vomicae  ;  and  in  this  malady  more  often  at  the  base  than  at 
the  apex.  According  to  the  shrinkage  or  change  in  the  shape 
of  the  chest,  or  where  in  the  pleura  or  pericardium  adhesions 
have  taken  place,  there  are  seen  changes  from  the  normal  in  the 
cardiac  impulse.  Other  changes  the  outcome  of  altered  relation- 
ships between  the  lungs  and  the  heart  may  be  manifest,  but  are 
sometimes  very  obscure.  If  the  compensatory  hypertrophy  of 
the  right  ventricle  suffers,  we  have  evidences  of  venous  stasis,  pul- 
sation of  the  jugulars,  edema,  enlarged  liver,  cyanosis,  and  the 


CROUPOUS    PNEUMONIA. 

like.  The  course  of  fibroid  phthisis  is  essentially  chronic,  and, 
on  the  whole,  progressive,  although  there  may  be  periods  of  fail- 
health,  and  yet  death  may  occur  from  intercurrent  disease. 

The  diagnosis  should  not  be  difficult  if  a  history  can  be 
obtained.  Chronic  tuberculosis  is  excluded  on  account  of  ex- 
cellent general  nutrition,  the  absence  of  fever,  and  the  mode  of 
onset.  In  fibroid  phthisis  there  is  a  history  of  chronic  cough  and 
expectoration,  with  repeated  blood-spittings,  physical  signs  of 
lung  destruction  (generally  of  one  side  and  often  with  the  for- 
mation of  cavities),  or  signs  of  shrinkage  and  hardening.  The 
heart  exhibits  hypertrophy  soon  or  late,  with  dilated  right  ven- 
tricle. The  disorder  may  be  confounded  with  chronic  pleurisy, 
in  which  there  is  also  much  contraction  of  the  side.  In  cancer 
of  the  lung  or  pleura  the  thoracic  physical  signs  are  similar,  but 
the  course  and  duration  are  quite  different. 

Prognosis. — A  sufferer  from  fibroid  phthisis  may  live  a  great 
many  years,  especially  if  the  individual  is  in  comfortable  circum- 
stances and  can  or  will  be  reasonably  careful.  The  danger  is 
from  intercurrent  diseases. 

Treatment. — Nothing  can  be  done  to  repair  the  damage  to 
the  parenchyma  of  the  lung  ;  much,  however,  can  be  done  to 
place  the  patient  in  good  health  and  keep  him  there.  In  the 
accomplishment  of  this  a  judiciously  regulated  outdoor  life,  atten- 
tion to  the  diet,  and,  above  all,  to  the  skin,  will  do  much  to 
lengthen  the  sufferer's  days.  Respiratory  gymnastics  are  cap- 
able of  doing  a  good  deal  in  improving  the  condition  of  the 
lung,  especially  suitable  exercises  in  a  wholesome  atmosphere. 
High  altitudes  are  theoretically  contraindicated,  because  of  the 
deficient  respiratory  capacity.  This  must  be  determined  in  each 
particular  case,  estimating  the  collateral  conditions,  whether  a 
dry  or  a  moist  climate  be  the  best.  Expectorants  are  to  be 
avoided  as  a  routine  measure,  but  must  be  prompt  and  efficient 
when  needed.  Potassium  iodid  is  useful  in  certain  stages  of 
bronchitis,  and  creasote  or  guaiacol  will  at  times  serve  a  useful 
end.  Cod-liver  oil  is  the  stand-by  always,  and  other  nutrient 
tonics — malt,  hypophosphites,  etc. — are  frequently  of  use. 

CROUPOUS  PNEUMONIA. 

Croupous  pneumonia,  or  lobar  pneumonia,  is  a  specific  inflam- 
matory disease  of  the  lungs  due  to  infection  by  the  bacillus 
lanceolatus  (pneumococcus)  accompanied  by  exudation  into  the 
vesicular  structure,  with  subsequent  consolidation.  Clinically,  it 
is  an  acute,  self-limited  disease,  manifested  by  high  fever,  dyspnea, 


4/2  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

cough,  and  rusty  sputum,  running  a  definite  course  of  from  four 
to  nine  days  and  ending  by  crisis. 

Causes. — Lobar  pneumonia  may  occur  at  any  age,  but  is  not 
nearly  so  common  in  infancy  as  bronchopneumonia,  being  rare 
before  the  age  of  two  years,  and  in  children  is  most  common 
between  five  and  ten.  Unlike  bronchopneumonia,  which  seizes 
upon  debilitated  children,  lobar  pneumonia  affects  those  who  are 
robust  and  in  vigorous  health.  Croupous  pneumonia  may  follow 
or  arise  as  a  complication  of  measles,  whooping-cough,  influenza, 
typhoid  fever,  and  tuberculosis,  but  in  children  under  three  years 
of  age  this  is  most  unusual.  Exposure  to  cold  is  the  predispos- 
ing cause  and  depressing  conditions  are  contributory,  but  the 
exciting  cause  is  the  bacillus  lanceolatus  (diplococcus  pneu- 
moniae)  of  Fraenkel.  This  microbe  holds  also  close  relations 
with  cerebrospinal  fever,  middle-ear  disease,  and  endocarditis. 
Among  other  bacteria  causing  pneumonia  may  be  mentioned  the 
bacillus  pneumoniae  (Friedlander)  as  well  as  the  streptococcus 
and  staphylococcus  pyogenes.  No  doubt  other  bacteria  are 
sometimes  responsible  for  croupous  inflammations,  such  as  the 
bacillus  typhi  abdominalis.  There  is  some  reason  to  believe  that 
this  form  of  pneumonia  is  contagious. 

Pathology. — The  lesions  of  lobar  pneumonia  occurring  in 
children  are  much  the  same  as  those  of  the  adult,  being  an  acute 
exudative  inflammation  extending  throughout  the  whole  of  one 
lobe  or  the  major  part  of  one  lung  or  limited  portions  of  both 
lungs.  The  stages  are  those  of  congestion,  red  hepatization, 
gray  hepatization,  and  resolution,  progressively,  just  as  in  the 
adult. 

During  the  first  stage,  or  the  stage  of  engorgement,  the  lung 
tissue  is  congested.  It  is  of  a  deep-red  color,  firmer  to  the  touch 
than  normally.  On  section  a  frothy  liquid  exudes,  made  up  of 
serum  and  blood.  The  lung  still  crepitates,  and  a  cut  portion 
will  float.  The  alveoli  contain  fibrin,  leukocytes,  and  detached 
epithelium.  The  capillaries  of  the  air  vesicles  are  dilated  and 
tortuous,  and  the  alveolar  epithelium  is  swollen.  The  first  stage 
lasts  a  few  hours  or  several  days.  When  the  output  of  inflam- 
matory products  has  reached  its  height,  these,  collected  within 
the  alveoli  and  terminal  bronchi,  increase  the  size  of  the  lung  as 
well  as  its  density  ;  hence  the  stage  of  red  hepatization.  The 
lung  is  of  dark-red  color,  solid,  airless,  and  firm.  It  is  easily 
friable,  cuts  like  liver,  and  sinks  in  water.  This  stage  occurs 
earlier  in  children  than  in  adults. 

Microscopically  studied,  the  alveoli  are  observed  to  be  filled 
by  threads  of  coagulated  fibrin,  in  the  meshes  of  which  are 


CROUPOUS    PNEUMONIA.  473 

seen  red  blood-corpuscles,  polynuclear  leukocytes,  and  alve- 
olar epithelium.  The  alveolar  walls  are  infiltrated,  and  leukocytes 
are  seen  in  the  interlobular  tissue.  Thereupon  follows  a  period 
in  which  the  exudate  becomes  changed  in  color  from  red  to  a 
mottled  gray  ;  this  is  called  gray  hepatization,  and  is  a  process 
of  degeneration  and  softening.  The  air-cells  are  filled  with  leu- 
kocytes. The  fibrinous  network  and  the  red  blood-corpuscles 
have  disappeared  from  the  alveoli.  Finally  comes  its  last  stage  ; 
in  this  the  exudate  is  softened.  Disintegration  and  degeneration 
of  the  cell  elements  continue  until  they  are  rendered  soft  and 
capable  of  absorption.  The  lymphatics  take  up  and  remove 
these  products,  and  this  is  called  resolution.  During  the  course 
of  an  ordinary  lobar  pneumonia  no  histologic  change  takes  place 
in  the  lung  structure  itself;  consequently  recovery  occurs  by 
resorption  and  expectoration  of  the  exudate. 

In  children  lobar  pneumonia  is  frequently  bilateral  ;  the  lobe 
most  frequently  affected  is  the  lower  one  of  the  left  lung,  and 
pneumonia  of  the  apex  is  quite  prevalent  among  children,  though 
rare  in  adults.  A  bronchitis  may  accompany  the  process  in  a 
fair  proportion  of  cases.  A  plastic  form  of  pleurisy  occurs  where 
the  consolidation  reaches  the  pleura  ;  more  rarely  an  effusion 
takes  place  and  empyema  may  result.  Pleurisy  of  a  mild  sort  is 
frequently  present  yet  unrecognized  ;  it  is  less  often  a  complica- 
tion in  lobar  pneumonia  than  in  bronchopneumonia. 

Symptoms. — Lobar  pneumonia,  being  a  primary  process, 
manifests  itself  abruptly,  with  few  or  no  prodromes.  The  serious- 
ness of  the  malady  is  promptly  defined  by  the  onset  of  convul- 
sions or  vomiting,  or  both,  usually  a  certain  amount  of  rigor  or 
chilliness,  with  a  pronounced  rise  of  temperature.  The  clearly 
marked  chill,  so  common  in  adults,  is  rarely  seen  ;  instead  of  this 
the  nervous  system  often  loses  its  balance  (convulsions)  or  a  mild 
delirium  often  appears,  or  the  stomach  rejects  its  contents.  The 
temperature  rises  rapidly,  and  inside  of  a  day  may  reach  104°  or 
105°  F.,  continuing  with  slight  daily  remissions  and  declining  by 
rapid  crisis  from  the  seventh  to  the  tenth  day.  It  often  then 
falls  below  the  normal.  The  pulse  is  full  and  bounding,  increas- 
ing in  rapidity  as  the  temperature  rises,  but  respiration  is  accel- 
erated in  even  greater  proportion  than  either,  so  that  the  pulse- 
respiration  ratio  of  one  breath  to  two  pulse-beats  is  pathognomonic 
in  this  disease.  Pain  is  usually  present,  referred  vaguely  to  the 
chest  or  abdomen  ;  dyspnea  may  become  a  most  urgent  symptom. 
A  short,  dry  cough  may  appear  early,  which  sometimes  seems  to 
give  rise  to  pain.  The  cough,  however,  may  not  come  on  until 
later,  and  changes  its  character  as  the  disease  progresses.  There 


474  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

is  rarely  any  expectoration  before  the  sixth  or  eighth  year,  and 
then  it  may  exhibit  the  rusty  character  common  in  adults.  The 
face  is  often  flushed,  or  circumscribed  spots  of  redness  appear  on 
the  cheek  ;  the  eyes  are  bright  and  the  facial  expression  is 
anxious  ;  the  alae  of  the  nose  are  dilated,  showing  increased 
inspiratory  effort.  In  the  milder  cases  there  are  restlessness  and 
irritability ;  in  severer  ones  there  is  apathy,  at  times  complete. 
Appetite  is  usually  lost,  and  sometimes  marked  digestive  disturb- 
ances persist  throughout  the  disease.  In  certain  severe  cases  the 
nervous  symptoms  are  prominent  throughout,  usually  in  propor- 
tion to  the  height  of  the  fever,  and  death  may  occur  in  a  convul- 
sion before  even  the  characteristic  physical  signs  appear.  If  the 
nervous  phenomena  appear  at  first  only,  they  are  of  little  gravity  ; 
if  they  arise  later,  they  are  of  gloomy  portent.  In  intensely 
severe  cases  the  dyspnea  and  cyanosis  develop  markedly,  the 
respiration  is  shallower,  the  pulse  more  rapid  and  weak,  the  child 
becomes  stuporous,  and  death  occurs  quietly  or  with  motor 
excitements. 

The  physical  signs  in  lobar  pneumonia  in  children  are  not  so 
clear  as  in  adults,  and  yet  when  present,  are  of  much  the  same 
character.  There  is  percussion  dullness  over  the  consolidated 
portion  of  the  lung,  with  increased  resonance  elsewhere.  Dull- 
ness on  percussion  is  sometimes  masked  by  areas  of  emphysema- 
tous  lung  overlying  the  consolidated  portion,  requiring  deep  per- 
cussion to  bring  out  the  flatness.  The  expansion  of  the  affected 
lung  is  seen  to  be  lessened.  Crepitant  rales  are  heard  in  about 
one-third  of  the  cases,  and  are  best  recognized  during  the  long, 
indrawn  breath  after  coughing.  The  breathing  is  distinctly 
bronchial  where  consolidation  has  occurred,  and  vocal  resonance 
and  fremitus  are  increased — not  very  trustworthy  signs.  In  the 
beginning  of  the  disorder  fine  rales  may  be  heard  here  and  there, 
more  rarely  in  children  than  in  adults  ;  during  resolution  moist 
rales  are  heard  extensively.  There  is  great  variation  in  physical 
signs  and  all  symptoms  ;  in  some  cases  the  cough  is  absent  until 
many  days  elapse ;  the  cough  and  physical  signs  sometimes 
remain  for  several  days  after  the  temperature  has  dropped.  The 
presence  of  pleuritic  exudate  produces  a  dullness,  with  only  a 
muffling  of  the  breath-sounds.  There  are,  moreover,  certain 
varieties  of  lobar  pneumonia  which  have  received  special  names 
and  vary  considerably  in  their  symptomatology,  in  some  cases 
strongly  simulating  meningitis  with  hyperpyrexia,  convulsions, 
delirium,  or  coma,  and  yet  without  cough  or  the  physical  signs 
of  pneumonia.  These  cases  are  liable  to  arise  among  debilitated 
children,  and  the  pneumonia  is  often  of  the  apex.  Abdominal 


CROUPOUS    PNEUMONIA.  475 

pneumonia  is  a  name  given  to  those  cases  marked  by  digestive 
disturbance,  vomiting,  diarrhea,  and  abdominal  pain.  These 
may  be  so  severe  as  to  simulate  peritonitis.  The  pneumonia  in 
these  cases  is  only  to  be  discovered  by  careful  search.  Wander- 
ing pneumonia  is  very  like  bronchial  pneumonia  in  certain  of  its 
symptoms,  but  not  so  entirely  similar  as  to  fail  of  a  differentiation. 

The  commonest  complication  of  croupous  pneumonia  is 
pleurisy,  but  it  is  usually  not  very  severe  and  may  entirely 
escape  detection.  The  effusion  may  be  plastic  or  occasionally 
purulent,  especially  when  following  measles  and  scarlet  and 
typhoid  fevers.  Pericarditis  may  complicate  the  pleurisy  or 
occur  alone.  The  meningeal  form,  or,  better  termed,  the  cere- 
bral form,  is  very  alarming,  but  rarely  does  this  indicate  a  true 
meningitis.  Disturbance  of  the  kidneys  occasionally  arises ; 
abscess  and  gangrene  are  rare  sequels. 

Diagnosis. — When  seen  in  the  fully  developed  form,  a  lobar 
pneumonia  is  difficult  to  differentiate  from  a  bronchial  pneumonia. 
Wandering  pneumonia  with  areas  of  fleeting  consolidation  is  even 
more  confusing.  The  abdominal  type  of  pneumonia  is  readily 
overlooked,  and  here  the  respiration  and  pulse-rate  must  be  care- 
fully measured.  The  suddenness  of  lobar  pneumonia  and  its 
high  fever,  vomiting,  and  convulsions  before  the  physical  signs 
are  manifest,  together  produce  a  marked  similarity  to  the  onset 
of  scarlatina.  Pleurisy  with  effusion  is  to  be  recognized  by  its 
movable  character,  absence  of  breath-sounds,  rales,  and  by 
changes  of  vocal  resonance  and  onset  with  pain. 

In  the  diagnosis  between  the  cerebral  form  of  pneumonia  and 
meningitis  it  is  important  to  bear  in  mind  that  in  the  former  we 
have  rapid  pulse  and  hurried  respiration.  In  meningitis  there  is 
usually  a  slower  pulse,  with  slow,  irregular  breathing.  In  lobar 
pneumonia  usually  a  number  of  its  own  characteristic  features 
will  appear  to  distinguish  it  from  the  marked  irregularities,  slow, 
insidious  onset,  irregular  temperature,  pulse  and  respiration  rates 
of  bronchial  pneumonia.  The  unilateral  character  of  lobar  pneu- 
monia will  mark  its  distinction  from  the  bilateral  manifestations 
usual  in  bronchial  pneumonia. 

Prognosis. — Bronchial  pneumonia  in  children  is  a  far  graver 
disease  than  primary  croupous  pneumonia.  In  the  secondary 
form  of  croupous  pneumonia,  however,  it  is  more  serious,  yet  in 
the  septic  cases  the  mortality  is  high.  Of  evil  omen,  too,  are 
pronounced  cerebral  symptoms,  hyperpyrexia,  and  great  dyspnea, 
but  experience  proves  that  even  the  severest  cases  recover  sur- 
prisingly. The  mortality  is  about  5  to  10  per  cent. — it  is  large 
under  three  years  but  very  small  from  that  age  to  ten  years. 


476  DISEASES    OF   THE    RESPIRATORY    ORGANS. 

THE  TREATMENT  OF  PNEUMONIA. 

It  has  seemed  to  us  better  to  include  under  the  treatment  of 
pneumonia  the  consideration  of  both  forms  common  in  children, — 
bronchopneumonia  and  lobar  orcroupous  pneumonia, — with  ref- 
erences, also,  to  pleuropneumonia  and  other  complications,  as 
there  are  a  number  of  points  common  to  the  treatment  of  all 
forms  of  bronchial  and  pneumonic  inflammations. 

When  one  is  confronted  with  a  well-developed  case  of  inflam- 
mation of  the  lungs  in  a  child,  it  is  far  from  easy,  sometimes 
practically  impossible,  to  differentiate  clearly  between  various 
forms.  In  the  treatment  of  such  it  is  imperative  to  put  the  suf- 
ferer to  bed  at  absolute  rest  and  to  control  the  environment, 
making  sure  of  a  uniform  degree  of  warmth,  which  should  be 
from  70°  to  74°  F.,  with  abundant  air, — not  less  than  1000  to 
1 200  cubic  feet  for  each  child, — and  to  be  prompt  with  means 
for  readily  changing  the  air  as  it  becomes  in  the  least  degree 
vitiated.  An  open  fireplace  with  fire  burning  is  one  of  the  most 
nearly  perfect  devices,  in  addition  to  whatsoever  other  arrange- 
ments may  already  exist  for  ventilation.  Even  in  a  hospital -ward 
air  modification  is  frequently  possible  as  above  suggested,  and 
always  to  be  welcomed.  It  is  a  distinct  advantage  to  modify  the 
air  of  the  room,  where  this  is  feasible,  by  some  volatile,  prefer- 
ably resinous,  principles  which  are  stimulating  to  the  respiratory 
mucous  membrane,  especially  when  dyspnea  is  a  marked  symp- 
tom. Here  it  is  well  to  surround  the  child  for  a  time  with  a  tent 
made  of  sheets,  such  as  is  used  for  croup,  and  in  this  place  a 
kettle,  on  which,  in  boiling  water,  may  be  vaporized  beechwood 
creasote,  pine-needle  oil,  turpentine,  compound  tincture  of  ben- 
zoin, or  eucalyptus.  There  should  be  as  little  disturbance  as 
possible  in  the  way  of  noise,  moving  objects,  and  the  like,  espe- 
cially when  cerebral  symptoms  supervene.  The  sufferer  should 
be  handled  as  little  as  possible  ;  frequent  examinations  are  entirely 
needless,  tending  to  exhaust  strength  and  patience.  During  the 
day  an  abundance  of  light  may  be  admitted,  sunlight  being  espe- 
cially welcome.  So  soon  as  night  falls  there  should  be  no  illu- 
mination excepting  such  subdued  light  as  is  necessary  for  the 
guidance  of  the  nurse. 

Bathing  is  of  the  utmost  use,  not  only  for  the  purpose  of  keep- 
ing the  skin  in  a  wholesome  continued  action,  thus  relieving  the 
strain  on  the  overburdened  lungs,  but  it  is  also  a  remedial  agent, 
and  enjoys  a  very  important  place  in  the  category  of  remedies, 
especially  during  the  stage  of  collapse  in  pneumonia,  usual  in 
the  bronchial  form.  A  bath  at  102°  to  105°  F.,  into  which  the 


THE  TREATMENT  OF  PNEUMONIA.  477 

child  may  be  plunged  for  a  moment,  materially  assists  a  failing 
heart  or  embarrassed  respiration  and  rouses  waning  powers. 
During  the  course  of  a  moderate  fever  a  bath  at  103°  to  104°  F. 
and  sponging  with  water  at  70°  to  80°  F.,  or,  if  the  child  is  strong, 
iced  water  applied  is  most  useful.  If  the  temperature  is  very 
high,  the  water  may  be  cooled  while  the  patient  is  in  the  bath, 
for  the  purpose  of  reducing  the  fever  to  a  reasonable  degree,  or 
towels  wrung  out  of  iced  water  wrapped  about  the  trunk  for  from 
ten  to  thirty  minutes  while  sitting  in  the  hot  bath.  The  fever 
per  se  may  be  let  alone  ;  it  is  generally  the  nervous  symptoms 
which  require  treatment,  and  upon  these  judicious  bathing  exer- 
cises an  excellent  control.  The  use  of  a  hot  foot-bath,  to  which 
may  or  may  not  be  added  a  small  quantity  of  mustard,  will  prove 
an  excellent  measure  in  relieving  delirium,  restlessness,  or  in- 
somnia. Some  recommend  the  addition  of  alcohol  to  a  warm 
sponge-bath,  and  then  fanning  the  skin  until  it  becomes  cooler. 
Some  immerse  the  patient  in  water  at  90°  F.  for  fifteen  minutes, 
followed  by  constant  rubbing,  keeping  the  feet  carefully  warm  the 
while.  There  are  those  who  recommend,  even  in  children,  the 
cold  pack  or  ice  poultice,  and  this  has  proved  of  the  utmost  value 
to  us.  Cold  produces  contraction  of  the  cutaneous  capillaries, 
followed  by  active  dilatation,  relieving  the  heart,  increasing  excre- 
tory action  and  the  elimination  of  toxins,  and  thus  reduces  the 
fever  and  the  cause  of  fever  (S.  Baruch).  The  application  of  cold 
produces  neurovascular  stimulation,  transmitted  to  the  heart,  in- 
creasing ventricular  force.  Baruch's  method  of  bathing  in  fever 
is  to  place  the  child  in  a  bath  at  95°  F.  and  bathe  the  face  with 
water  at  75°  -f  F.  Ice  is  then  added  to  the  bath  until  85°  F.  is 
reached.  During  the  whole  of  this  period  of  five  minutes  friction  is 
maintained  over  the  entire  surface.  This  may  be  repeated  in  from 
four  to  six  hours  if  the  temperature  remains  above  IOI°  F.  The 
minimum  temperature  of  the  bath  should  be  80°  F.  If  during 
the  interval  the  temperature  remains  high,  compresses  at  70°  F. 
may  be  employed.  The  cold  pack,  if  used  continuously,  should 
always  be  done  with  great  care.  The  cloths  are  wrung  out  of 
water  at  65°  F.  or  70°  F.  and  laid  around  the  patient,  who  is 
then  enveloped  in  blankets.  Hot  bottles  should  be  kept  at  the 
feet,  especially  if  any  shivering  or  chilliness  occurs.  If  it  con- 
tinues, stop  at  once.  The  ice  poultice  is  made  by  incorporat- 
ing finely  crushed  ice  in  a  cold  poultice  of  flaxseed  or  Indian 
meal.  As  has  been  said,  pyrexia  is  of  itself  not  a  matter  for 
alarm,  and  hyperpyrexia  rather  indicates  profound  blood-poison- 
ing, which  needs  other  and  more  radical  remedies  than  cooling 


4/8  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

measures.  The  child  should  not  be  allowed  to  remain  long 
lying  on  the  back  for  fear  of  hypostasis. 

Clothing.— —The  clothing  of  the  child  should  be  of  wool,  as 
thin  as  possible,  but  entirely  protective  in  quality  and  extent. 
The  bedclothing  should  be  of  the  lightest,  and  yet  sufficiently 
warm.  Thin  woolen  sheets  are  best,  but  a  blanket  worn  next 
above,  with  a  sheet  underneath,  does  very  well,  and  in  milder 
cases  muslin  sheets  above  and  below  may  be  used,  but  linen 
never.  The  body  clothing  should  be  so  adjusted  as  to  be  readily 
taken  on  and  off,  especially  that  over  the  shoulders  and  chest, 
by  being  open  down  the  front  and  back,  so  that  counterirritants 
may  be  readily  applied,  poultices  or  stupes  or  fixed  dressings, 
according  to  the  requirements  of  the  various  states. 

Food. — Inasmuch  as  the  strength  of  the  patient  is  sorely  taxed 
in  all  forms  of  lung  disease,  the  utmost  care  needs  to  be  exercised 
that  he  shall  maintain  every  atom  of  strength  by  means  of  food 
in  such  quality  and  amount  as  shall  require  no  strain  on  the  pro- 
cesses of  digestion  and  yet  supply  abundant  force.  For  infants, 
in  whom  bronchopneumonia  is  one  of  the  commonest  and  often 
fatal  forms,  instruction  as  to  feeding  has  been  given  elsewhere. 
Food  should  be  of  the  simplest  nature  for  such  little  ones,  whether 
well  or  ill,  and  during  the  height  of  the  febrile  process  and  well 
into  the  stage  of  convalescence  had  best  be  guarded  by  digest- 
ants.  For  somewhat  older  children,  accustomed  to  taking  solid 
food,  an  ordinary  fever  diet  is  admissible.  This  should  consist 
largely  of  milk,  which  may  also  be  predigested  or  guarded  by 
digestants,  supplemented  by,  or  alternated  with,  stimulating  broths 
of  various  sorts,  and  later  semisolid  food,  as  soft-boiled  eggs  and 
meat  purees.  Only  when  the  fever  is  well  past  may  a  variety  be 
introduced  or  increased.  The  very  great  tendency  in  some  forms 
of  pneumonia  to  be  accompanied  by,  and  some  believe  caused  by, 
putrefactive  agents  in  the  intestines  makes  it  important  to  be  on 
guard  against  evidences  of  gastro-intestinal  disease  and  to  meet 
them  promptly.  The  bowels  must  be  quickly  relieved  of  any 
disturbing  matter  by  laxatives  or  simple  enemata,  or  both,  or 
some  antifermentative  medicines  may  be  employed  to  control  this 
tendency. 

Stimulants. — While  it  may  not  be  wise  to  employ  alcohol 
and  other  stimulants  as  routine  practice,  nevertheless  in  our  judg- 
ment it  is  well  to  err  on  the  side  of  prudence  and  administer 
alcohol  as  soon  as  there  is  a  clear  indication  for  its  use,  for,  aside 
from  apparently  sustaining  properties,  it  many  times  simulates  a 
food.  The  most  valuable  property  of  alcohol  is  to  act  as  a  tran- 
quillizing agent.  This  it  does  particularly  well  in  children  and  in 


THE  TREATMENT  OF  PNEUMONIA.  479 

disorders  of  their  lungs.  The  form  of  alcohol  used  may  be  a 
definite  amount  of  whisky  or  brandy,  or  some  believe  that  in 
disturbances  of  organs  of  respiration  Jamaica  rum  is  peculiarly 
valuable.  For  very  little  infants  the  milder  form  of  wine-whey 
serves  an  admirable  purpose,  and  is  certainly  less  irritating  to  a 
disturbed  stomach  than  the  stronger  preparations.  Some  accept 
more  readily  the  heavier  wines,  as  sherry  and  port ;  but  cham- 
pagne, so  valuable  in  adults,  is  not  especially  acceptable  to  chil- 
dren. Aromatic  spirit  of  ammonia  is  stimulating  ;  caffein  or  its 
preparations,  it  may  be  tea  or  coffee  as  ordinarily  made  (or,  at 
least,  well  made),  is  of  admirable  temporary  use  in  failing  heart 
action,  sometimes  far  better  than  alcohol,  indeed,  or  even  strych- 
nin or  digitalis.  It  has  a  happy  effect  in  certain  forms  of  delirium, 
alone  or  along  with  alcohol,  a  bromid,  codeiri,  or  sulphonal.  The 
ammonium  salts  are  useful  as  cardiac  stimulants  as  well  as  for 
their  expectorant  properties. 

Counterirritants. — There  is  considerable  variation  in  the 
opinions  of  the  most  eminent  physicians  as  to  the  usefulness  of 
Counterirritants  for  hyperemia  or  consolidated  areas  of  the  lung. 
Our  own  belief  is  that  they  serve  a  very  excellent  purpose  if 
judiciously  employed.  Any  constant  application  to  the  chest, 
if  of  considerable  extent,  is  liable  to  the  objection  that  the  skin 
becomes  macerated  when  moist  applications  are  continued  for 
many  hours  or  days,  and  this  maceration  can  not  but  be  objec- 
tionable in  many  ways.  It  inhibits  to  a  great  extent  elimination 
from  the  skin,  which  needs  to  be  encouraged  in  every  way, 
weakens  the  capillary  vessels,  while  at  the  same  time  it  relieves 
their  tension  and  renders  the  skin  susceptible  to  the  effects  of 
exposure.  The  occasional  use  of  poultices  has  the  advantage 
of  acting  as  an  excellent  febrifuge  as  well  as  relieving  the  cuta- 
neous capillaries,  at  the  same  time  determining  the  blood  to  the 
surface  and  away  from  hyperemic  areas.  They  are  of  distinct 
efficacy  when  there  is  high  fever  accompanied  by  hot  diy  skin, 
painful  dyspnea,  with  a  dry  cough  or  tightness  of  the  chest,  or 
scanty  expectoration.  Our  method  of  using  poultices  (as  an 
occasional  practice)  where  there  seems  an  indication  for  them  is 
this  :  Poultices  should  be  made  moderately  thick  and  quite  hot, 
— about  105°  F.,  or  even  110°  F.  when  the  patient  has  become 
accustomed  to  their  use, — about  the  thickness  of  a  hand,  and 
of  a  size  to  cover  the  posterior  surface  of  the  lungs  on  both 
sides  completely.  They  should  also  be  covered  front  and  rear 
with  thin  cloth,  as  cheese-cloth,  and  so  adjusted  that  the  child  may 
lie  upon  this  poultice  and  not  be  oppressed  by  any  weight  upon 
the  chest.  This  is  allowed  to  remain  in  contact  from  a  half-hour 


480  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

to  an  hour.  It  is  then  cautiously  and  quickly  removed.  Then  im- 
mediately rub  in  with  the  hand,  while  warm,  some  counterirritant, 
as  turpentine,  one  dram,  to  sweet  oil,  one  ounce,  or  camphor  oil  or 
amber  oil.  This  is  applied  over  the  surfaces  where  the  poultices 
lay,  and  also  over  the  entire  chest.  Then  immediately  envelop 
the  chest  in  cotton-wool,  well  warmed  and  dry.  The  child  may 
now  be  allowed  to  remain  quiet  for  three  hours,  and  if  necessary, 
this  is  to  be  repeated — the  poultice  on  the  back,  thorough  inunc- 
tion of  a  counterirritant  both  back  and  front,  and  a  fresh  layer  of. 
cotton  to  surround  the  chest.  It  may  be  necessary  to  use  this 
every  three,  four,  or  five  hours,  for  the  first  day,  and  possibly 
once  or  twice  applied  on  the  second  day.  Beyond  this  it  is 
rarely  necessary  to  make  use  of  local  heat  and  moisture,  though 
occasionally  it  may  be  carried  on  to  the  third  or  fourth  day.  The 
cotton  should  not  be  covered  with  silk,  which  inhibits  cutaneous 
exhalation  too  much  ;  it  ought  to  be  changed  when  it  becomes 
in  the  least  befouled,  and,  better,  after  each  poultice  afresh.  It 
sometimes  happens  that  no  poultices  are  needed  ;  then  a  turpen- 
tine stupe,  for  a  quarter  to  a  half-hour,  once  applied,  or  possibly 
twice,  is  sufficient.  These  certainly  relieve  pain  when  present, 
and  also  have  an  excellent  effect  upon  the  bronchitis. 

The  use  of  any  of  these  applications  may  excite  the  child  and 
do  more  harm  than  good.  If  so,  mere  hot  foot-baths  will  serve, 
followed  by  the  silk-and-cotton  jacket. 

Some  authorities  use  flaxseed  poultices,  hot,  to  which  one  part 
mustard  is  added  to  five  or  six  of  flaxseed  meal,  and  applied 
until  the  skin  is  well  reddened  ;  then  this  slipped  off  and  hot, 
dry  flannel  placed  over  the  part.  For  pleuropneumonia  or  a 
concomitant  pleurisy  this  form  of  counted rritation  is  excellent. 
Other  authorities  use  a  cotton  jacket,  with  or  without  oiled  silk, 
throughout  the  attack.  To  us  this  seems  a  rather  unattractive 
measure,  but  is  highly  recommended,  and  is  far  less  troublesome 
than  the  systematic  poulticing.  It  may  be  well  to  follow  active 
poulticing  with  the  oiled-silk  jacket,  which  is  certainly  effective 
and  convenient. 

Medicines. — The  use  of  medicine  should  be  purely  symptom- 
atic. It  is  not  well  to  direct  too  much  attention  to  the  checking 
of  a  cough,  unless  this  excites  or  exhausts  the  patient  ;  the 
cough  is  relieved  in  a  very  great  majority  of  cases  by  attentions 
of  a  local  kind — by  the  use  of  sprays,  application  of  astringents 
to  the  pharynx,  upper  air-passages,  and  oleaginous  sprays  or 
vapors  containing  resinous  principles.  Opium  has  not  so  great 
an  effect  in  depressing  respiration  as  is  often  feared,  but  must  be 
used  carefully.  It  is  of  great  value  in  relieving  the  character  of 


THE  TREATMENT  OF  PNEUMONIA.  481 

the  cough  ;  used  sparingly  and  in  certain  combinations  it  pro- 
duces a  happy  effect  upon  respiration  and  delirium.  Opium  has 
an  objectionable  effect  upon  the  intestines,  especially  where  these 
are  distributed,  unless  diarrhea  should  supervene,  which  is  com- 
paratively rare.  From  ^  of  a  grain  to  three  grains  of  Tulley's 
powder  is  recommended.  Dover's  powder  in  the  form  of  an 
elixir  enjoys  the  confidence  of  others.  Paregoric  has  its  admirers, 
and  the  elixir  of  opium  is  one  of  the  best  preparations.  Two  or 
three  well-directed  doses  are  better  than  continued  administra- 
tion. Syrups  of  all  kinds  are  to  be  avoided  as  menstrua ;  a  little 
glycerin  with  aromatic  water,  or  elixir  of  pepsin,  or  simple  elixir 
is  better. 

Cold  is  the  best  antipyretic,  but  it  must  be  borne  in  mind  that 
during  extremely  hot  weather  a  longer  application  must  be  made 
than  in  cold.  If  the  extremities  are  chilly,  avoid  cold  baths. 
During  this  condition  a  hot  bath  is  better  and  more  efficient  in 
reducing  temperature,  because  with  cool  extremities  the  interior 
of  the  body  may  be  hot,  and  hot  baths  bring  the  blood  to  the 
surface,  thus  changing  its  site  and  relieving  congestion.  During 
the  use  of  cold  baths  it  is  wise  to  apply  warmth  to  the  feet  in  the 
way  of  hot  bottles.  A  good  form  of  cold  pack  is  to  apply  it 
from  the  waist  down,  leaving  the  arms  free,  and  keeping  the  feet 
warm  the  while.  A  small  baby  may  be  wrapped  in  a  single  wet 
towel  and  covered  with  a  blanket.  This  may  be  repeated  every 
five  or  ten  minutes.  If  the  child  is  extremely  weak,  the  pack 
may  be  left  on  and  cold  water  poured  over  it  from  time  to  time. 
Extreme  watchfulness  must  be  maintained  that  the  temperature 
does  not  drop  to  subnormal,  whereupon  artificial  heat  must  be 
again  applied.  Feeble  babies  are  better  for  a  warm  or  hot  bath, 
with  tepid  pack,  using  water  with  or  without  alcohol  ;  or  a  warm 
bath  gradually  cooled,  the  little  bodies  being  rubbed  the  while. 
The  heart  may  suffer  seriously  toward  the  end  of  pneumonia,  and 
is  always  depressed,  needing  stimulation  soon  or  late.  Heart 
failure  is  better  prevented  than  cured.  Alcohol  is  not  the  best 
cardiac  stimulant  for  children,  and  the  disturbed  condition  of  the 
kidneys  generally  present  renders  it  unwise  to  use  too  freely. 
Digitalis  stimulates  both  the  heart  and  arteries,  increasing  per- 
ipheral resistance.  It  is  well  given  in  a  few  good  doses  and  then 
omitted  or  lessened.  When  an  effect  is  desired  only  upon  the 
heart,  spartein  or  strophanthus  is  best. 

The  coal-tar  antipyretics  have  a  certain  value,  to  be  used  occa- 
sionally, not  so  much  for  the  relief  of  pyrexia  as  for  their  expec- 
torant qualities.  Phenacetin  does  this  not  quite  so  well  as  anti- 
pyrin  (phenazone),  but  each  of  them  assists  in  the  relief  of  nerve 
31 


482  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

disturbances.  Aconite  is  not  altogether  free  from  danger,  but  re- 
lieves the  circulation  admirably.  Liquor  ammonii  acetatis,  espe- 
cially in  the  form  of  mistura  ferri  acidi,  has  a  happy  effect  in 
depleted  subjects,  in  those  for  whom  iron  is  indicated,  or  in  whom 
there  is  insufficient  urinary  elimination  or  disordered  kidneys.  For 
the  stimulation  of  the  heart  digitalis,  strophanthus,  and  spartein 
each  have  their  place.  Also  strychnin  is  to  be  regarded  as  a 
valuable  ally.  Strychnin,  with  its  happy  effect  upon  the  respira- 
tory activities,  is  frequently  given,  especially  when  there  is  a  clear 
indication  for  its  need  as  an  invigorator  of  nervous  force,  and  it 
usually  should  be  used  in  full  doses,  from  -g-^-  to  -fa  of  a  grain, 
three  or  four  times  a  day.  One  of  the  most  reliable  remedies  is 
nitroglycerin,  which  dilates  the  capillaries  and  thereby  aids  circu- 
lation immensely.  Potassium  iodid  also  has  this  effect,  likewise 
acting  as  an  eliminant.  The  ammonium  salts  have  their  place 
and  their  advocates.  Carbonate  of  ammonia  is  a  good  heart 
stimulant,  producing  a  very  brief  effect,  but  liable  to  disturb  the 
stomach.  Toxemia  calls  for  thorough  stimulation,  not  too  long 
continued,  or  lessened  as  the  needs  decrease.  Alcohol  is  here 
indicated  in  sufficiently  large  amounts,  and  in  acute  cardiac  failure 
even  hypodermically.  A  rapid  heart-beat  is  always  suspicious 
and  calls  for  full  stimulation  at  once.  Chlorid  of  ammonia  is 
useful  toward  the  end  of  pneumonia  and  aids  the  cellular  activ- 
ities. Aromatic  spirits  of  ammonia  is  quite  as  good,  and  more 
acceptable  for  its  effect  upon  the  heart.  Quinin  in  the  beginning 
.of  convalescence  seems  to  exert  a  peculiarly  beneficial  effect  upon 
the  cough,  and  sustains  the  action  of  the  nervous  system. 

Pulmonary  edema  requires  emptying  the  lungs  by  dry  cups  or 
an  occasional  emetic,  as  apomorphin,  -^-^  of  a  grain  subcutane- 
ously,  and  stimulation  of  the  heart  and  excretory  organs.  A 
sharp  purgative  will  assist  in  this.  For  cyanosis,  in  addition  to 
the  cardiac  tonics  and  vasodilators  the  direct  or  indirect  applica- 
tion of  oxygen  is  of  the  highest  value  to  save  or  prolong  life. 

Edema  from  renal  diseases  is  efficiently  relieved  by  pilocarpin, 
•fa  to  fa  of  a  grain  subcutaneously.  Hemorrhage  occasionally 
occurs  from  the  lung,  but  is  liable  to  be  due  to  cardiac  compli- 
cation and  is  manifested  in  the  trachea  or  bronchi. 

Gangrene  of  the  lung  occasionally  complicates  pneumonia 
resulting  from  the  infectious  diseases,  suppurative  processes,  or 
foreign  bodies.  Here  stimulating  inhalations  are  indicated, 
especially  of  the  resinoids, — tar,  turpentine,  terebene, — on  hot 
water  or  nebulized. 

Hernia  of  the  lung  sometimes  occurs,  pouting  out  at  each 
respiratory  action.  Should  deformities  of  the  chest-walls  oc- 


PLEURISY.  483 

cur,  respiratory  gymnastics  help  more  than  anything  else,  and 
should  be  continued  for  months  or  years.  The  bronchial  and 
mediastinal  glands  frequently  become  congested  and  inflamed  in 
divers  diseases  of  the  thorax,  though  frequently  are  the  result  of 
protracted  bronchial  and  nasal  catarrh,  or  metastasis  from  other 
glandular  disturbances,  especially  in  rachitic  or  tubercular  cases. 
The  principal  symptoms  are  those  of  pressure  upon  the  tracheal 
veins,  or  nervous  attacks  of  coughing  with  crowing  inspirations, 
changed  voice  sounds,  bronchial  respiration,  dullness  over  the 
sternum  (upper  part),  and  dullness  about  the  interscapular  region. 
The  control  of  this  complication  is  difficult,  and  consists  of  ab- 
sorbents applied  externally,  mercurial  ointment,  or  potassium 
iodid  and  iodin.  Internally,  arsenic  increasingly  and  other  aids 
to  nutrition  should  be  used. 


PLEURISY. 

Pleurisy  or  pleuritis  in  infancy  and  childhood  is  almost  always 
a  secondary  disease.  Sometimes  there  is  inflammation  of  the 
pleura  without  any  appreciable  exudate.  Such  cases  are  called 
dry  or  fibrinous  pleurisies.  More  often  the  disorder  is  accom- 
panied by  an  exudation  of  fluid — serous,  serofibrinous,  or  puru- 
lent— into  the  pleural  cavity.  When  the  exudate  is  visibly 
purulent,  the  disease  is  called  empyema  or  purulent  or  sup- 
purative  pleurisy.  Serous  effusions  are  less  frequent  in  children 
than  in  adults  ;  very  rare  under  three  years.  Empyema  is  much 
more  common  in  the  young  than  in  older  folk. 

Causes. — The  greatest  number  of  cases  occur  from  birth  to 
the  fifth  year  ;  the  next  greatest  during  the  following  five  years 
up  to  the  age  of  ten.  It  appears  rather  more  frequently  in  boys 
than  in  girls,  and  more  often  on  the  left  than  upon  the  right  side. 
Pleurisy  is  generally  unilateral.  There  is  usually  some  recog- 
nizable antecedent  disease,  but  this  is  sometimes  not  clearly  evi- 
denced ;  it  is  most  commonly  a  disorder  of  the  lungs,  especially 
pneumonitis.  It  is  possible  to  find  only  exposure  to  cold  and 
dampness  the  exciting  cause,  and  many  believe  this  to  be  suffi- 
cient. It  is  probable,  however,  that  such  factors  act  rather  as 
predisposing  causes,  reducing  the  constitutional  resistance,  there- 
by preparing  a  soil  for  the  invasion  of  pathogenic  microbes. 
Injuries  to  the  chest-walls  are  also  credited  with  being  a  sufficient 
cause.  It  must  also  be  borne  in  mind  that  in  children  there  are 
fleeting  forms  of  pneumonia  lasting  but  a  few  days,  which  may 
precede  or  coexist  with  effusions  of  the  pleura.  Recent  bacterio- 
logic  researches  on  the  pleural  exudate  have  demonstrated  un- 


484  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

mistakably  the  presence  of  the  staphylococcus  and  streptococcus 
(Koplik),  and  shown  this  disorder  to  be  similar  to  the  affection  in 
the  adult. 

In  some  effusions,  however,  no  microbic  elements  are  exhib- 
ited. At  present  we  are  in  a  position  to  assume  the  diplococcus 
as  the  connecting  link  between  the  process  in  the  lung  and  the 
pleuritic  inflammation.  The  exposure  to  devitalizing  agencies, 
here  as  elsewhere,  lessens  the  resistance  of  the  constitution  to  the 
host  of  micro-organisms  which  constantly  lurk  in  the  upper  air- 
passages.  Our  difficulties  in  accounting  for  the  means  and  ave- 
nues through  which  these  reach  so  remote  and  protected  a  part 
as  the  pleural  cavity  are  frequently  almost  insuperable.  The  in- 
fectious diseases,  various  forms  of  tonsillitis,  the  exanthemata, 
typhus  and  typhoid  fever,  pertussis,  influenza,  suppuration,  and 
abscess  of  mediastinal  glands  may  precede  and  directly  cause 
an  attack  of  pleurisy.  Suppuration  elsewhere,  with  or  without 
a  recognizable  pyemia,  also  septic  wounds  and  acute  bone  dis- 
ease, may  bring  about  a  pleuritis.  Abscesses  in  the  abdominal 
cavity  or  involving  any  of  the  viscera,  and  tubercular  disease  of 
any  part,  may  be  competent  causes  for  this  disease. 

Pathology. — In  the  mild  forms  of  pleurisy  so  commonly  oc- 
curring the  membrane  at  first  is  congested,  red,  and  covered  with 
a  thin  coating  of  lymph.  It  loses  its  natural  luster.  This  occurs 
also  in  various  forms  of  acute  pneumonia.  There  are  scattered 
a  few  fibrinous  threads  or  adhesions.  Should  the  process  cease 
here,  it  is  called  dry  pleurisy.  In  somewhat  severer  cases  the 
fibrin  formation  is  more  extensive  and  diffused  over  both  the  pul- 
monary and  costal  pleura,  causing  distinct  thickenings.  In  still 
worse  forms  of  pleurisy,  where  the  inflammation  continues,  an 
exudate  is  formed  which  may  be  in  character  serofibrinous,  fibrin- 
ous, or  purulent.  The  last  condition  is  termed  "empyema." 

The  effusion  is  an  inflammatory  one  and  is  a  distinctly  secre- 
tory process,  not  a  mere  transudation,  as  in  hydrothorax.  In  mere 
hydrothorax  we  have  the  effect  of  a  simple  difference  of  intra- 
vascular  tension  between  the  active  pressure  in  the  blood-vessels 
and  lymphatics  and  the  negative  tension  in  the  thorax. 

Inflammation  leading  to  serous  effusion  presents  another  factor, 
the  secretory  power  of  the  irritated  pleural  epithelium. 

This  serum  or  seropus  may  .be  much  or  little  ;  it  usually  con- 
tains leukocytes  and,  possibly,  bacteria  ;  it  may  be  clear,  turbid, 
or  opaque ;  yellow  or  green,  and  thin  or  creamy.  In  large 
effusions  the  heart  is  displaced  and  the  lungs  are  compressed. 
Oftentimes  adhesions  are  so  dense  as  to  seal  the  two  surfaces  of 
lung  and  costal  pleura  together,  forming  limited  cavities.  This 


PLEURISY.  485 

binding  of  the  lung  and  ribs  may  seriously  impair  functional 
activity  of  the  breathing  organ.  In  serous  pleurisy  this  encyst- 
ing is  much  more  common  in  children  than  in  adults,  and  may 
be  recovered  from.  It  is  almost  always  encysted  in  the  purulent 
form.  In  tubercular  pleurisy  the  inflammatory  exudate  may 
cause  considerable  thickening  of  the  pleural  surface  as  well  as  an 
output  of  fibrin  and  fluid.  Here  the  effusion  may  be  encapsu- 
lated by  the  adhesions,  while  the  lung  is  progressively  crippled 
and  misshapen  by  the  changes.  It  is  not  altogether  clear 
whether  an  acute  pleuritis  with  serous  effusion  is  a  separate  dis- 
ease from  pleuritis  with  purulent  effusion,  or  whether  the  difference 
between  the  two  is  simply  one  of  degree,  differing  in  the  amount 
of  pus-cell  formation.  Practically,  it  would  seem  so  ;  this  last 
form,  with  the  purulent  exudation,  probably  began  as  such  and 
continued  so.  The  latter  is  empyema,  and  the  former  the  true 
pleurisy. 

Symptoms. — The  special  symptoms  of  dry  pleurisy  are  pain, 
sharp,  severe,  and  localized,  increased  on  inspiration  ;  and  the 
painful  areas  are  usually  tender  to  the  touch.  The  pain  may  be 
referred  to  the  abdomen.  A  cough  of  a  tickling  character 
accompanies  most  cases.  In  the  dry  form  of  pleurisy  friction 
sounds  are  to  be  heard  over  the  affected  spot,  generally  of  a 
moist  or  crackling  kind,  superficial,  and  not  altered  by  coughing. 
When  this  occurs  as  a  complication  of  pneumonia,  the  only 
evidence  may  be  pain.  It  generally  runs  a  favorable  course  in  a 
few  days  or  a  week.  In  the  purulent  variety  there  are,  usually, 
constitutional  symptoms  referable  to  sepsis.  Physical  signs  are 
diminished  movement  of  the  affected  side,  bulging  of  the  inter- 
costal spaces,  and,  if  the  effusion  is  large,  the  measurement  of 
the  affected  side  is  increased.  If  the  effusion  is  considerable, 
especially  of  the  left  side,  the  apex-beat  of  the  heart  is  displaced 
to  the  right  and,  possibly,  downward. 

When  pleurisy  arises  as  an  acute  affection,  the  clinical  picture 
differs  little  from  that  accompanying  any  acute  disease  with  fever, 
especially  such  as  affect  the  chest,  as  in  pneumonia,  with  which 
this  is  usually  coexistent.  Moreover,  one  symptom  may  mask 
another.  There  may  be  a  cough  from  the  beginning,  accom- 
panied by  evidence  of  pain,  such  as  a  cry.  These  symptoms 
may  increase  along  with  dyspnea,  and  the  later  phenomena  are 
those  of  extreme  weakness  and  emaciation.  In  the  more  insidious 
form  the  first  febrile  symptoms  subside,  lulling  suspicion.  Older 
children  may  complain  of  pain  now  and  then,  with  cough,  little 
or  more,  yet  with  an  increasing  pallor  and  prostration.  The 
fever  may  be  high  from  the  start  (105°  F.),  or  vary  from  day  to 


486  DISEASES    OF    THE    RESPIRATORY    ORGANS 

day.  When  the  temperature  falls,  it  usually  is  not  quite  to 
normal,  and  in  the  following  days,  should  the  pleurisy  continue, 
the  fever  again  goes  up  to  101°  or  102°  F.,  remitting  in  the 
morning.  The  pulse  is,  as  a  rule,  particularly  high  and  tense. 
Dyspnea  is  the  most  obvious  symptom.  If  the  chest  is  touched, 
there  is  usually  evidence  of  pain  ;  the  child  resents  being  lifted 
and  will  prefer  to  lie  on  the  affected  side.  Cerebral  symptoms 
may  supervene,  similar  to  those  in  pneumonia. 

Prognosis. — This  depends  on  the  nature  and  character  of  the 
effusion.  In  the  primary,  simple  form  prognosis  is  good  ;  in  the 
purulent  form  it  is  grave. 

Physical  Signs. — Inspection  reveals  lack  of  movement  on  the 
affected  side,  apparent  in  even  very  young  infants  ;  this  is  in  sharp 
contrast  to  the  labored  or  hurried  motions  of  the  unaffected  side 
of  the  thorax. 

When  the  exudation  is  extensive,  there  is  also  bulging  of  the 
affected  side  ;  the  intercostal  spaces  are  not  necessarily  prominent : 
they  may  be  retracted  ;  at  least  the  affected  side  seems  smoother 
and  fuller  than  the  other. 

The  effusion  which  accompanies  pneumothorax  must  not  be 
overlooked,  though  in  children  this  is  a  rare  condition.  It  is 
usually  purulent,  but  sometimes  serous.  The  fluid,  according  to 
its  mobility,  obeys  more  readily  the  forces  of  gravity  in  this  con- 
nection. It  is  a  matter  of  remark  how  little  this  is  true  of  the 
ordinary  pleural  effusion. 

Palpation  tells  little  in  children,  especially  in  dry  pleurisies  or 
with  slight  effusion.  Absence  of  vocal  (or  cry)  fremitus,  partial  or 
complete,  over  the  areas  of  flatness  is  of  much  significance. 

The  percussion-note  over  a  thickened  pleura  or  mass  of  exu- 
date  is  conspicuously  dull  or  flat,  but  subject  to  strange  and 
rapid  variations  in  children.  Light  percussion  skilfully  applied 
is  required  to  bring  out  surface  dullness,  whereas  if  this  is  made 
too  vigorously,  the  undertones  of  the  distant  lung  mask  this  in 
the  thin  childish  tissues.  Koplik  calls  attention  to  the  peculiarly 
"  wooden  "  resistance  to  the  percussing  finger.  On  the  unaffected 
side  the  note  is  exaggerated,  even  tympanitic. 

Auscultation  is  an  uncertain  guide  in  pleurisy  occurring  in 
children.  We  may  hear  natural  breathing  sounds  above  the  fluid 
level ;  and  below  that  they  are  bronchial  or  diminished  or  absent,  or 
the  respiratory  sounds  may  not  be  much  changed  even  in  a  chest 
filled  with  effusion.  There  is  more  or  less  accompanying  involve- 
ment of  the  lung  tissues  and  bronchial  tubes,  giving  rise  to  rales 
and  altered  sounds,  but  they  change  most  confusingly.  Dis- 
placements of  the  viscera,  heart,  liver,  etc.,  are  not  so  common 


PLEURISY.  487 

nor  so  significant  as  in  adults,  and  are  rare  in  children  under  three 
years  of  age.  It  is  well  to  note  the  position  of  the  apex  of  the 
heart,  however,  which  is  usually  pushed  toward  the  sternum  by 
large  left-sided  effusions.  The  apex-beat  is  then  to  be  seen  at 
the  ensiform  cartilage. 

Diagnosis. — In  dry  pleurisy,  seldom  occurring  in  children 
under  ten  or  twelve  years  of  age,  we  have  symptoms  similar  to 
the  same  condition  in  adults  :  sharp  localized  pain  increased  on 
inspiration,  tenderness  on  pressure  or  movement,  and  a  tickling 
cough.  The  pain  may  not  be  referred  to  the  affected  side,  but 
to  the  abdomen. 

In  pleurisy  with  effusion  the  reliable  signs  are :  Flatness  on 
percussion,  immobility,  absence  of  rales  or  friction  sounds,  dis- 
tant bronchial  breathing,  absence  of  vocal  (or  cry)  fremitus,  and 
bulging  of  the  affected  side. 

From  pneumonia  it  may  be  distinguished  by  the  lesser  tem- 
perature and  prostration  in  pleurisy  and  the  mildness  of  the 
symptoms  generally,  other  than  the  sensory  ones. 

Localized  encapsulated  pleurisies  are  evidenced  by  character- 
istic changes  in  the  voice  or  fremitus  over  circumscribed  areas, 
dullness  or  altered  percussion-note,  and  especially  the  wood-like 
resistance  to  the  percussing  finger. 

In  children  the  exudate  is  liable  to  become  suddenly  puru- 
lent ;  hence  it  is  imperative  to  learn  at  once  its  character,  which 
any  one  can  readily  and  safely  do  by  an  exploratory  puncture 
with  a  stout  hypodermic  needle  of  large  caliber,  made  with  strict 
care  and  antiseptic  precautions.  Outline  the  area  of  greatest 
dullness,  wash  the  skin  with  soap  and  water,  then  with  alcohol 
or  bichlorid  i  :  2000.  Take  a  strong  hypodermic  needle,  or, 
much  better,  the  aspiration  needle  to  be  used  for  both  explora- 
tion and  immediate  evacuation,  or  a  needle  such  as  is  used  for 
administering  the  diphtheria  antitoxin  ;  drive  this  quickly  ^  or 
Y^  of  an  inch  (not  too  far)  into  one  of  the  intercostal  spaces, 
entering  the  area  of  greatest  dullness,  and  withdraw  the  piston. 
The  nurse  must  be  warned  to  hold  the  child  firmly,  lest  by  a 
sudden  movement  the  lung  be  wounded  or  the  needle  be  broken 
off  by  striking  a  rib.  If  no  fluid  is  withdrawn,  the  needle  is  to  be 
promptly  extracted  and  a  clean  piece  of  rubber  plaster  or  iodoform 
collodion  used  to  cover  the  puncture.  The  absence  of  fluid  in  the 
needle  does  not  mean  that  there  is  none  in  the  pleura  ;  hence  the 
operation  should  be  repeated  elsewhere,  at  once. or  on  a  subse- 
quent occasion.  This  little  operation  is  almost  harmless  ;  never- 
theless it  must  be  done  with  full  precautions.  The  fluid  thus 
withdrawn  should  be  carefully  examined  for  bacteria.  If  chain 


488  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

cocci,  staphylococci,  or  the  diplococcus  pneumoniae  are  demon- 
strated in  a  serous  exudate,  we  may  be  prepared  for  purulent 
change  (Koplik).  If  tubercle  bacilli  are  revealed,  this  is  of  grave 
importance  ;  their  absence,  however,  does  not  prove  the  absence 
of  tubercular  infection.  The  tubercular  form,  however,  is  rare  in 
children. 

Treatment. — The  treatment  of  pleurisy  is  in  great  measure  a 
preventive  one,  since  it  is  so  constantly  a  complication  of  various 
existing  disorders,  such  as  pyemia,  the  pneumonias,  or  even  of 
pericarditis  and  peritonitis,  and  the  acute  fevers,  rheumatism,  and 
diphtheria.  In  children  the  symptoms  are  exceedingly  decep- 
tive, for  among  them  pain  is  oftentimes  absent,  although  the  one 
most  distinctive  symptom  in  the  adult.  When  pleuritis  is  estab- 
lished, recognized  or  suspected,  the  chest  should  be  immobilized ; 
adhesive  plaster  is  objectionable  for  children,  though  efficacious, 
the  underlying  skin  being  liable  to  irritation.  A  broad  bandage 
or  towel  adjusted  with  safety-pins  acts  better.  Cold  relieves 
pain  promptly.  This  may  be  in  the  shape  of  an  ice-bag  applied 
dry,  or  cloths  wrung  out  of  iced  water,  or  thick  flannel  which 
has  been  laid  upon  a  cake  of  ice,  this  again  covered  with  dry 
flannel  or  rubber  cloth  and  fresh  chilled  flannel  thus' laid  on  fre- 
quently. If  morphin  is  used  to  control  pain,  it  is  best  given 
hypodermically.  Dry  cupping  is  useful  if  it  does  not  excite. 
Warm  or  hot  fomentations  may  do  better  for  feeble  children. 
Quinin  has  a  good  effect  upon  temperature,  preventing  the  rise 
if  used  in  time.  It  is  best  given  dry  and  added  to  a  little  simple 
elixir,  or  in  the  form  of  a  suppository.  Pilocarpin  is  theoretic- 
ally useful,  but  only  suitable  for  vigorous  children.  If  the  heart 
is  weak,  cardiac  stimulants  must  be  given  promptly  and  in  suffi- 
cient doses.  Calomel  is  useful  to  relieve  the  bowels  and  stimu- 
late the  kidneys,  along  with  acetate  or  citrate  of  potassium  or 
the  iodids.  The  use  of  gray  powder,  a  very  ancient  remedy, 
decried  by  some,  is  strongly  advocated  by  the  English  physicians. 
Cases  of  serous  effusion,  if  not  extensive  or  causing  serious 
interference  with  respiration  or  heart  action,  may  be  treated 
symptomatically  and  recovery  follows.  If  the  acute  symptoms 
progress  rapidly  and  the  accumulations  endanger  life  from  pres- 
sure depressing  the  liver,  stomach,  and  spleen,  accompanied,  as 
it  often  is,  by  dyspnea  and  engorgement  of  the  cervical  veins,  an 
operation  is  imperative  and  the  fluid  must  be  removed.  The 
usual  method  is  by  aspiration,  repeated  if  necessary  in  twelve  or 
twenty-four  hours.  Occasionally  incision  and  drainage  are  de- 
manded when  the  chest  is  rapidly  refilled. 

As  has  been  said,  it  is  better  to  use  the  aspirator  in  initial 


PLEURISY.  489 

punctures  and  thus  remove  fluid  at  once.  If  the  fluid  withdrawn 
is  deeply  blood-stained,  it  is  best  to  stop  the  operation.  To  con- 
tinue would  be  to  invite  more  blood  to  the  inflamed  lung,  which 
probably  underlies  the  process.  If  the  fluid  is  blood-stained  and 
no  great  tension  is  present,  it  is  again  well  to  cease  and  rely  on 
medicinal  remedies. 

Tubercular  effusions  are  rare  in  children,  and  if  tubercle  is 
the  underlying  process,  it  is  unwise  to  interfere  surgically, 
provided  they  do  not  produce  signs  of  positive  tension  amount- 
ing to  pressure,  which  would  endanger  the  functions  of  the  other 
thoracic  viscera  (Maguire).  Tubercular  effusions  are  of  rarer 
occurrence  than  has  been  generally  supposed. 

When  the  acute  symptoms  have  subsided,  the  main  reliance  is 
upon  hygienic  and  nutritional  measures.  Indications  are  :  open- 
air  life  and  moderate  exercise,  which  will  aid  recovery  by  improv- 
ing the  general  health  and  the  respiratory  activities.  In  adults 
it  is  different  because  of  the  tendency  in  them  to  heart  failure. 

If  adenoid  growths  of  the  pharynx  are  present  and  cause 
dyspnea,  they  may  be  safely  removed  to  great  advantage. 

INTERLOBAR  PLEURISY. 

Interlobar  pleurisy  is  that  form  of  pleurisy  which  develops  and 
becomes  encysted  between  two  lobes  of  one  lung.  It  is  almost 
always  purulent.  Normally  the  pleural  surfaces  bounding  a  fis- 
sure are  simply  apposed,  but  if  adhesions  cause  the  margins  of  the 
fissure  to  unite,  the  interlobar  pleura  becomes  isolated  and  forms 
a  pocket — a  closed  localized  sac  favorable  to  the  development 
of  an  encysted  pleurisy.  This  pleurisy  may  be  deep-seated  and 
obscure,  and  in  the  beginning  may  simulate  a  pulmonary  dis- 
order. The  pus-cavity  may  occupy  the  whole  interlobar  space 
or  only  a  part.  Sometimes  several  secondary  pockets  are  found. 
After  adhesions  are  formed  and  fluid  is  effused,  the  normal  situ- 
ation of  the  fissure  is  often  entirely  altered. 

Causes. — Interlobar  pleurisy  is  most  often  primary.  It  may 
be  secondary,  usually  to  pneumonia.  The  primary  cases  fre- 
quently owe  their  origin  to  the  pneumococcus. 

Physical  signs  are  often  obscure.  Particularly  in  the  begin- 
ning the  diagnosis  offers  great  difficulties.  The  signs  which  usu- 
ally indicate  inflammation  of  the  lung  (rales,  relative  dullness, 
etc.)  are  apt  to  predominate  and  thus  mask  the  first  clinical 
manifestations  of  pleuritis.  It  is  only  after  eight  or  ten  days, 
when  the  effusion  has  grown  rather  large  (at  least  from  seven  to 
nine  ounces),  that  the  indication  becomes  clearer.  Percussion 
now  allows  one  to  mark  out  behind  or  in  the  axilla  a  more  or 


49°  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

less  extended  zone  of  dullness,  corresponding  to  the  interlobar 
fissure.  The  persistence  of  sonorous  zones  above  and  below 
the  dull  zone,  along  the  vertebrae,  at  the  base  of  the  thorax, 
and  in  the  semilunar  space  will  permit  the  elimination  of  the  sero- 
fibrinous  pleurisy.  To  distinguish  an  encysted  interlobar  pleurisy 
then  becomes  possible. 

Diagnosis. — The  principal  functional  symptoms  are  three : 
dyspnea,  hemoptysis,  and  coughing  up  of  pus  from  rupture  of  the 
sac.  The  dyspnea  is  more  severe  than  in  ordinary  pleurisy  ;  hence 
in  the  presence  of  a  pleural  affection  involving  intense  dyspnea  one 
should  suspect  first  of  all  an  encysted  pleurisy.  Hemoptysis  may 
be  abundant  and  recurrent.  It  has  appeared  sometimes  before 
and  sometimes  after  rupture.  It  seems  due  to  ulceration  of  the 
walls  of  the  cavity.  Rupture  is  much  more  frequent  in  encysted 
pleurisy  than  in  ordinary  empyema.  It  occurs  almost  always 
earl)',  and  may  be  predicted  a  day  or  so  beforehand  by  the  fetid 
odor  of  the  breath.  The  symptoms  are  variable.  If  the  dis- 
charge is  abundant,  the  patient  is  taken  suddenly  with  violent 
dyspnea,  and  coughs  up  quantities  of  offensive  mucopurulent 
sputum.  Most  often,  however,  the  rupture  consecutive  to  an 
encysted  pleurisy  is  not  attended  with  considerable  discharge  of 
pus  at  one  time.  Once  the  pus-cavity  is  empty,  it  collapses 
partly  and  may  completely  cicatrize.  Usually  signs  of  a  cavity 
appear,  the  fever  runs  high,  sweating  is  constant,  the  patient 
emaciates  rapidly,  and  without  surgical  intervention  a  fatal  result 
is  inevitable.  Medical  treatment  at  this  stage  is  valueless. 

PLEUROPNEUMONIA. 

Pleuropneumonia  is  recognized  as  a  separate  variety  of  pneu- 
monia accompanied  by  an  excessive  degree  of  pleurisy,  along  with 
exceptionally  marked  consolidation.  The  pleurisy  in  these  cases 
usually  arises  consentaneously  with  the  pneumonia,  or  it  may  fol- 
low. The  cause  is  oftenest  the  pneumococcus.  The  form  is  a 
bronchopneumonia  in  two-thirds,  a  lobar  pneumonia  in  one-third, 
of  the  cases.  The  left  lung  is  affected  in  two  cases  out  of  three, 
the  pleurisy  being  of  both  lungs,  as  a  rule,  in  different  degrees. 
Both  surfaces  of  the  pleura  are  found  covered  with  greenish- 
yellow  fibrin,  glueing  the  opposite  walls  together,  affecting  also, 
probably,  the  pericardium  and  the  diaphragm.  The  intensity  of 
the  inflammation  is  liable  to  cause  a  fatal  result  early  in  the 
course  of  the  disease.  When  the  chest  is  filled  with  pus,  a  con- 
dition of  empyema  results.  The  exudate  may  rarely  be  only 
serous.  Absorption  may  take  place,  followed  by  adhesions, 


PLEUROPXEUMONIA.  49! 

usually  extensive.  The  symptoms  differ  little  from  those  of  a 
combined  pneumonia  and  pleurisy  and  chiefly  in  the  degree  of 
severity  of  the  constitutional  symptoms,  pain,  temperature,  and 
subsequent  exhaustion.  The  auscultation  sounds  are  exceed- 
ingly puzzling. 

The  prognosis  is  naturally  bad ;  infants  usually  die  in  the 
acute  stage. 

The  diagnosis  from  empyema  or  simple  effusion  is  not  so 
difficult  if  punctures  are  made.  It  is  difficult  to  withdraw  the 
fluids  unless  a  pocket  be  accidentally  punctured. 

HYPOSTATIC  PNEUMONIA  can  not  be  readily  diagnosed,  but 
commonly  accompanies  death  in  infants  from  chronic  or  wasting 
disease,  particularly  marasmus.  The  lesion  postmortem  is  seen 
to  be  confined  to  a  superficial  strip  along  the  posterior  border  of 
both  lungs,  not  involving  the  deeper  structures,  as  in  atelectasis. 
This  should  not  be  regarded  as  accounting  for  the  death.  There 
is  seldom  dullness  on  percussion,  the  only  sounds  being  fine, 
moist  rales. 

GANGRENE  OF  THE  LUNG  occasionally  occurs  in  feeble  children 
of  poor  nutrition,  usually  under  three  years  of  age,  and  follow- 
ing the  course  of  depressing  diseases,  particularly  bronchopneu- 
monia  and  measles.  The  immediate  cause  is  some  mechanical 
shutting-off  of  the  circulatory  activity  in  a  portion  of  the  lung. 

The  distinctive  symptoms  are  the  gangrenous  odor  of  the 
breath  and  the  expectoration  of  fragments  of  decomposed  lung 
tissue.  Death,  however,  is  liable  to  occur  before  these  evidences 
are  clear,  and  the  diagnosis  is  usually  made  from  postmortem 
findings. 

PULMONARY  COLLAPSE  (ACQUIRED  ATELECTASIS). — A  condition 
of  collapse  may  come  upon  areas  of  a  competent  lung  during 
the  progress  of  pulmonary  disease  or  owing  to  causes  which 
profoundly  disturb  the  lung  circulation  or  the  pressure  of  air  in 
the  lungs. 

This  may  arise  from  compression  or  obstruction.  Collapse 
due  to  compression  commonly  accompanies  pleuritic  effusion  or 
pneumothorax,  pericardial  effusion,  cardiac  enlargement,  deformi- 
ties of  the  chest,  and  thoracic  or  mediastinal  new  growths.  This 
may  be  partial  or  complete,  and  becomes  less  remediable  the 
longer  it  remains,  especially  if  there  exist  dense  pleuritic  adhe- 
sions, which  last  may  be  the  chief  barrier  to  reexpansion.  Col- 
lapse from  obstruction  is  due  to  two  factors — blocking  of  the 
bronchial  tubes,  great  or  small,  and  incompetent  respiratory 
vigor.  Holt  says  that  this  first  factor  has  been  greatly  exag- 
gerated. If  the  lumen  is  narrowed,  the  stenosis  is  most  liable 


492  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

to  result  in  emphysema.  When  a  bronchus  is  obstructed  from 
any  cause,  usually  from  a  foreign  body  or  from  external  pressure 
preventing  the  entrance  of  air,  that  portion  of  lung  beyond  this 
point  becomes  slowly  collapsed  ;  if  a  primary  bronchus,  the  whole 
lung  ;  if  a  lobar  division,  the  whole  lobe  ;  if  a  bronchiole,  a  small 
contiguous  area.  The  collapsed  portion  becomes  depressed 
below  the  normal  surface,  is  of  dark-red  color,  highly  vascular, 
and  resembles  pneumonia — in  which  it  may  result.  Holt,  also 
from  special  observation,  declares  that  the  development  of  em- 
physema is  much  more  likely  to  result  from  stenosis,  due  to 
bronchitis  of  the  smaller  tubes,  etc.,  rather  than  to  atelectasis. 

Collapse  of  areas  of  the  lung  may  come  on  slowly  and  gener- 
ally in  feeble  infants,  rachitic  and  otherwise  depressed,  accom- 
panied by  bronchitis  resembling  congenital  atelectasis,  with  much 
the  same  phenomena.  The  symptoms  are  rapid  respiration, 
dyspnea  on  inspiration,  sinking  in  of  the  chest-walls,  cyanosis, 
and  impaired  peripheral  circulation. 

EMPYEMA. 

Empyema  or  purulent  pleuritis  usually  accompanies'  or  follows 
pneumonitis,  especially  pleuropneumonia,  and  is  more  common 
in  children  than  in  adults.  It  may  complicate  or  follow  the  acute 
infectious  diseases  and  especially  tuberculosis  (oftener  in  children 
several  years  of  age),  and  is  a  sequel  of  pyemic  states  of  vari- 
ous sorts,  umbilical  sepsis,  and  bone  or  joint  inflammations, 
appendicitis,  or  purulent  peritonitis. 

Bacteriologic  research  has  done  much  recently  to  add  to  our 
knowledge  of  the  causes.  The  pneumococcus  is  found  in  most 
purulent  pleural  exudates,  notably  those  following  pneumonia ; 
next  common  are  the  pyogenic  agents,  streptococcus  and  staphy- 
lococcus,  alone  or  with  the  pneumococcus  ;  and,  finally,  the 
tubercle  bacillus  is  often  present,  but  not  so  easily  demonstrated. 
It  is  most  rare  for  empyema  in  a  young  child  to  result  from  a 
serous  effusion  which  has  been  gradually  converted  into  a  puru- 
lent one.  Empyema  usually  succeeds  that  form  of  pleurisy  in 
which  there  is  first  an  exudation  of  fibrin,  with  an  excess  of  pus- 
cells.  Sacs  or  pockets  may  exist  or  form  by  slight  adhesions  in 
the  pleural  cavity,  into  which  the  pus  is  poured  and  collected. 
The  subdivisions  are  large  or  small,  but  they  tend  to  become 
larger  and  are  found  usually  posteriorly,  but  also  elsewhere  in 
the  chest.  The  sacs  may  be  divided  by  septa  ;  hence  the  evacu- 
ation of  one  does  not  empty  the  chest,  except  at  that  point.  The 
pus  may  not  be  all,  or  nearly  all,  at  the  bottom  of  the  chest,  but 


EMPYEMA.  493 

exist  merely  as  a  line  of  half  an  inch  or  so  in  depth  at  the  middle 
or  upper  part. 

Even  when  the  accumulation  is  great,  the  lung  does  not  float 
on  the  fluid,  but  is  surrounded  by  it,  causing  a  compression,  dis- 
placing the  heart,  diaphragm,  and  the  abdominal  viscera,  and 
there  results  a  bulging  of  the  chest-wall.  If  the  lung  is  thus 
interfered  with  for  a  long  time,  its  elasticity  is  liable  to  be 
much  impaired,  adhesions  grow  dense,  and  subsequent  expansion 
never  becomes  perfect.  Pus  may  burrow  into  a  bronchus  and 
discharge.  Also  a  chronic  change  takes  place  in  the  paren- 
chyma of  the  lung,  producing  the  so-called  "  fibroid  phthisis." 
Early  and  adequate  surgical  relief  removes  the  possibility  of  seri- 
ous damage.  Pericarditis  is  a  serious  complication  in  younger, 
and  pulmonary  tuberculosis  in  older,  children.  Endocarditis 
rarely  occurs  ;  this  is  true  also  of  gangrene  of  the  lung  and 
thrombi. 

Symptoms. — The  symptoms  of  empyema  are  similar  to  those 
of  a  pleurisy  with  effusion  ;  sometimes  less  marked,  but,  as  a 
rule,  giving  evidence  of  greater  systemic  depression,  a  higher 
temperature  range  coming  on  suddenly  and  sometimes  irregularly. 
Along  with  these  are  found  the  evidences  of  effusion  in  circum- 
scribed areas  of  consolidation,  or  narrow  tracts,  or  extensively. 
Also  there  are  the  usual  symptoms  of  pulmonary  disease  :  more 
or  less  cough,  dyspnea,  pain,  etc.  The  pulse  is  rapid  and  seldom 
strong,  but  not  so  weak  as  might  be  expected.  Empyema  in 
children  is  much  more  insidious  than  in  adults — is,  indeed, 
oftentimes  unsuspected  in  spite  of  most  careful  observations. 
In  long-standing  cases  there  are  seen  marks  of  chronicity : 
clubbed  fingers,  swelling  of  the  feet,  urinary  changes,  etc. 

Diagnosis. — The  history  of  the  case,  the  antecedent  or  accom- 
panying conditions,  will  point  the  differences,  as  a  rule,  between 
a  simple  serous  pleural  effusion  and  the  purulent  form.  "  If  the 
child  be  under  three  years  of  age,  the  fluid  is  almost  certain  to 
be  purulent ;  and  from  the  third  to  the  seventh  year  pus  is  much 
more  often  found  than  serum"  (Holt).  The  exploring  needle 
should  be  promptly  and  frequently  used,  as  early  differential 
diagnosis  is  most  important  for  treatment  and  prognosis.  Pus 
may  not  flow  from  the  needle  for  many  reasons — because  the 
needle  is  too  small  or  short  or  is  pushed  through  too  far,  or  the 
pus  may  be  too  thick  or  may  be  sacculated,  etc.  Hence  repeated 
explorations  are  to  be  encouraged  under  due  precautions.  (See 
Pleurisy.)  A  study  of  the  blood  will  aid  the  diagnosis.  (See 
Diseases  of  the  Blood.) 

In  empyema  there  is  flatness  over  the  whole  lung  or  lower 


494  DISEASES    OF    THE    RESPIRATORY    ORGANS. 

half,  with  no  rales  or  friction  sounds,  and  the  heart  is  displaced. 
Auscultatory  phenomena  are  misleading  ;  the  character  of  the 
breath-sounds  is  feeble,  and  breathing  is  distant  and  bronchial. 

Prognosis. — When  the  case  is  treated  promptly  and  surgically, 
the  outlook  is  favorable  to  a  continuance  of  life.  If  the  condi- 
tion of  the  patient  is  good  when  the  disease  begins,  it  is  still 
more  favorable,  though  age  is  an  important  factor ;  so  is  the 
nature  of  the  essential  cause  and  the  early  or  late  stage  of  the 
malady. 

Perfect  recovery  can  be  expected  in  favorable  cases,  and  that 
without  chest  retraction  or  spinal  curvature.  When  these  de- 
formities are  marked,  there  have  been  errors  of  treatment,  of 
which  long  neglect  is  the  chief.  Cases  not  treated,  or  not  until 
too  late,  often  die  from  exhaustion,  sepsis,  perforated  bronchi, 
choking,  tuberculosis,  or  visceral  degeneration. 

Treatment. — Pus  in  the  pleural  cavity  must  at  once  be  evacu- 
ated by  incision  and  drainage.  The  aspirating  needle  is  of  great 
service  to  establish  the  diagnosis,  but  is  of  no  value  in  treatment 

If  there  is  difficulty  in  introducing  a  rubber  drainage-tube  of 
sufficient  size  to  permit  the  pus  to  flow  freely,  a  small  portion  of 
one  or  more  ribs  should  be  resected.  The  pleural  cavity  must 
not  be  washed  out,  as  experience  has  shown  this  to  be  a  highly 
dangerous  procedure.  Immediate  collapse  and  death  of  the 
patient  have  resulted  in  not  a  few  instances.  If,  after  a  time,  the 
lung  does  not  expand  and  the  discharge  of  pus  ceases,  an  exten- 
sive resection  of  the  ribs  should  be  performed. 

Estlander,  Keen,  and  Schede  have  devised  operations  of  this 
character.  This  allows  the  chest-wall  to  sink  in  toward  the 
collapsed  lung,  and  adhesion  occurs  between  the  two  pleural 
surfaces. 

Delorme  has  recently  had  success  in  four  cases  by  an  improve- 
ment on  these  methods.  He  resects  the  ribs  in  line  of  the  skin 
incision,  and  turns  them  back  with  the  soft  parts  as  one  flap, 
removes  the  thickened  pleura  from  the  collapsed  lung,  and  re- 
turns the  flap  to  its  place.  His  operation  leaves  the  lung  in  a 
condition  to  regain  its  normal  expansibility. 

Cases  will  be  met  with,  however,  in  which  an  operation  can 
not  be  performed.  The  family  may  refuse,  or  it  may  occur  on 
both  sides  of  the  chest.  Empyema  occasionally  does  get  well 
by  resorption.  The  great  danger  is  that  of  septic  infection, 
carrying  acute  inflammation  elsewhere,  or  resulting  in  a  depress- 
ing septicemia. 

Repeated  aspirations  have  been  known  to  effect  much  reliefer 
partial  recovery. 


CHAPTER  XIV. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 


NERVOUS  MANIFESTATIONS  IN  THE  DISEASES  OF 

CHILDREN. 

A  subject  which  often  fails  to  engage  the  attention  of  practi- 
tioners of  medicine  in  dealing  with  the  disorders  of  infants  and 
children  is  the  nervous  manifestations  often  encountered.  If  these 
could  be  more  clearly  understood,  they  would  furnish  guiding 
lines  enabling  us  often  to  avert  threatened  calamities. 

The  equation  between  functional  activities  and  external  condi- 
tions which  is  called  health  depends  primarily  upon  two  factors 
— nervous  control  and  cellular  integrity.  The  chief  item  in 
equipment  of  the  infant  to  maintain  health  is  capacity  to  resist 
those  counterinfluences  which  perpetually  assail.  To  this  resist- 
ance we  trust  in  a  rather  blind  and  confiding  fashion,  and  our 
efforts  are  usually  confined  to  endeavors  to  adjust  the  more  obvi- 
ous external  conditions  of  life  to  the  varying  needs  of  the  organ- 
ism and  in  the  use  of  remedies  which,  according  to  our  knowl- 
edge of  physiologic  influences,  best  modify  and  control  the 
conspicuous  departures  from  normal  processes.  The  young  child 
is  known  to  be  peculiarly  susceptible  to  influences  which  disturb 
normal  equilibrium,  and  hence  it  suffers  to  a  much  greater  degree 
from  even  the  lesser  irritations  than  adults. 

Two  influences  stand  prominent  in  forming  this  lessened  resist- 
ance in  infancy  and  childhood — cellular  instability  and  the  incom- 
plete development  of  the  nervous  system.  Along  with  these 
there  are  many  other  factors  which  bear  relation  to  embryonal 
conditions,  merging  into  normal  attitudes  which  afford  valuable 
indications  to  the  student  of  vital  phenomena  and  which  the 
average  medical  student  omits  to  estimate  with  sufficient  care. 

It  would  seem  that  among  even  the  better  educated  and  more 
capable  practitioners  the  child  is  looked  upon  too  much  as  merely  a 
small  human  being,  for  whom  a  modification  of  ordinary  remedial 
measures  is  required,  proportioned  to  the  age  and  weight,  but 

495 


496  DISEASES    OF    THE    NERVOUS    SYSTEM. 

calculations  as  to  age  and  developmental  processes  bear  little  or 
vaguely  upon  practical  conclusions. 

The  older  writers — many  of  them  at  least — keenly  appreciated 
these  facts  and  described  admirably  many  infantile  phenomena 
which  could  not  be  explained  by  the  meagerness  of  the  then  state 
of  physiologic  knowledge.  Later  observers  have  given  much 
study  to  the  elucidation  of  the  phenomena  thus  recorded  and 
have  amplified  their  descriptions.  Where  it  becomes  necessary 
to  study  conditions  of  obscurity,  it  too  often  transpires  that  no 
notice  was  taken  of  phenomena,  come  and  gone,  through  which 
alone  it  would  have  been  possible  to  trace  the  steps  of  disease, 
which  then  presents  the  utmost  complexity. 

Perhaps  in  no  department  of  nosology  is  this  more  apparent 
than  in  the  group  of  conditions  which  are  known  as  disorders  of 
the  nervous  system.  However,  long  before  we  reach  this  branch 
of  medicine,  or  when  diseases  of  the  brain  or  spinal  cord  come 
in  for  attention,  there  are  many  states  dependent  upon  temporary 
disturbances  of  nervous  equilibrium  which  require  estimation. 
For  instance,  along  with  commonly  recurring  symptoms  which 
point  to  obvious  disturbances  of  the  digestive  or  respiratory 
or  other  organs,  there  may  or  may  not  be  evidences  of  neurosis  ; 
in  proportion  as  these  arise  in  children  of  vigorous  constitution, 
good  heredity,  and  wholesome  upbringing — in  short,  of  sound 
cellular  stability — they  are  fair  indices  of  the  gravity  and  extent 
of  the  disorder.  If,  on  the  contrary,  they  appear  in  the  persons 
of  those  whose  outward  seeming  is  good  enough,  but  concerning 
whom  it  can  be  learned  that  they  are  of  neurotic  inheritance  or 
vicious  environment,  or  both,  then  we  may  still  assume  that  the 
infection  or  disease  is  exerting  serious  influence  upon  an  irritable 
organism,  and  the  prognosis  is  far  worse,  not  only  as  to  the  out- 
come of  the  immediate  attack,  but  revealing  latent  weakness. 
Again,  it  is  possible  these  neurotic  phenomena  are  such  as  may 
be  expected  to  repeat  themselves  in  like  or  similar  fashion  upon 
the  recurrence  in  these  enfeebled  bodies  of  even  slight  evidences 
of  disease,  hence  not  of  deep  significance  ;  or,  finally,  they  may 
indicate  that  latent  tendencies  or  lesions  are  thus  placed  in  evi- 
dence and  enable  us  to  predicate  dangerous  amplifications  in  the 
future. 

Owing  to  the  imperfect  state  of  development  of  the  nervous 
system  in  the  earlier  months  or  years  of  childlife,  the  existence 
of  paralyses  is  not  so  readily  determined  ;  and  such  evidences  of 
defect  or  disorder  in  the  central  nervous  organization  are  often 
not  observed  until  their  progress  is  a  serious  disablement.  Such 
movements  as  are  made  by  babies  are  usually  of  reflex  origin, 


NERVOUS    MANIFESTATIONS.  497 

and,  being  not  consciously  produced,  they  are  less  capable  of 
control  and  not  fully  nor  accurately  performed.  In  a  fair  pro- 
portion of  children,  moreover,  there  are  inherent  defects  of 
development  other  than  those  due  to  normal  developmental 
delays.  These  hereditary  variations  from  the  customary  processes 
of  growth  in  some  instances  are  overcome  in  due  time,  producing, 
it  may  be,  slowness  of  growth  in  functional  activities  or  departures 
from  normal  types.  The  earlier  these  traits  are  recognized  and 
placed  under  suitably  modifying  influences,  the  better  the  result. 

To  discover  evidences  of  neural  disturbance  or  disease,  it  is 
imperative  to  observe  the  child  while  entirely  naked  ;  and  while 
thus  closely  inspecting,  note  the  smallest  aberrations  in  structure, 
proportion,  or  voluntary  movements.  This  requires  the  critical 
eye  of  a  trained  artist,  only  to  be  acquired  by  much  practice, 
coupled  with  large  knowledge  of  the  progressive  stages  of  out- 
line and  proportion  which  illustrate  normal  growth.  In  the 
majority  of  instances  the  child  will  be  subjected  to  this  scrutiny 
if  there  is  some  disorder  noted  by  the  parents,  and  these  phe- 
nomena under  consideration  must  not  escape  our  attention  or  be 
thrust  aside  by  the  others. 

The  unstable  state  of  equilibrium  in  the  cerebrospinal  cells  in 
the  young  child  renders  exaggerations  of  motion  even  more 
common  than  those  of  sensation.  The  lesser  degrees  of  motor 
exaggeration,  such  as  tremor,  are  comparatively  rare  and  most 
difficult  to  account  for.  Spasms  are  more  frequently  encountered, 
but  are  often  so  slight  that  it  requires  veiy  nice  and  watchful 
observation  to  detect  their  earlier  manifestations.  A  mother  can 
readily  see  what  is  invisible  to  the  most  shrewdly  observant 
physician  or  nurse,  and  her  testimony  is  always  to  be  courteously 
accepted  ;  not  so  her  conclusions.  Spasmodic  states  are  often 
of  the  gravest  significance,  and  much  importance  must  be 
allowed  them  in  any  clinical  history.  The  indications  for  treat- 
ment thus  evidenced  are  most  clear,  and  these  are  absolute  rest 
for  mind  and  body  and  the  prompt  removal  of  whatsoever  source 
of  irritation  can  be  found  to  exist,  whether  it  be  mechanical,  or 
toxic,  or  environmental.  Attention  of  this  sort  may  prevent  the 
occurrence  of  the  larger  motor  excitement,  convulsion,  which 
is  always  a  grave  symptom,  and  increasingly  so  if  prolonged 
or  repeated.  The  conclusion  to  be  reached  in  estimating  the 
gravity  of  the  significance  of  any  of  these  motor  excitements 
brings  us  to  one  or  another  of  the  horns  of  this  dilemma. 
Either  the  underlying  disease  process  must  be  of  an  overwhelm- 
ing character,  or  the  nature  of  the  cellular  integrity  of  the  child 
is  inherently  unstable.  Some  children  and  certain  families  are 
32 


498  DISEASES    OF    THE    NERVOUS    SYSTEM. 

thrown  into  spasms  or  convulsions  by  very  little  things,  whereas 
others,  even  under  closely  analogous  circumstances,  never  mani- 
fest any  perturbation  of  the  centers  of  motion.  Disturbances  of 
sensation  also  are  subject  to  many  variations,  according  to  the 
degree  of  the  individual  stability.  Undoubtedly  some  children 
— indeed,  some  families  and  races — are  relatively  insusceptible  to 
pain  and  differ  even  more  widely  in  their  capacity  to  endure. 
The  greatest  stoicism  or  Spartan  fortitude  is  sometimes  exhibited 
by  veiy  young  children,  even  though  their  constitutions  suffer  in 
consequence.  Others  cry  aloud  at  the  least  element  of  discom- 
fort, which  is  readily  elevated  by  them  into  a  conception  of 
agony.  It  is  needful,  however,  to  be  on  our  guard  against 
ignoring  evidences  of  pain,  and  if  possible  determining  its  source 
and  character.  Bear  in  mind  that  children  are  most  susceptible 
of  suggestion  and  easily  acquire  and  can  be  made  to  relinquish 
conviction  as  to  disturbances  of  sensation.  It  is  difficult  at  all 
times  for  children  to  differentiate  between  the  paresthesias,  and 
it  is  a  great  puzzle  to  differentiate  or  to  apply  tests  for  sensory 
variations.  The  conditions  producing  alterations  in  sensibility 
are  rare  in  infancy,  excepting  those  producing  tendernesses,  such 
as  rheumatism,  neuritis,  the  inflammations,  as  of  scurvy,  rickets, 
or  Pott's  disease,  or  the  simpler  problems,  as  injuries  or  abscess. 

Anesthesias  are  observed  to  follow  or  accompany  the  palsies 
of  the  infectious  diseases.  When  pain  accompanies  paralysis  in 
a  lower  extremity  or  the  trunk,  we  must  suspect  Pott's  disease, 
whether  deformity  be  discoverable  or  not.  Localized  tenderness 
along  a  nerve-trunk  arouses  fear  of  a  neuritis.  In  an  epidemic 
of  poliomyelitis  reported  by  one  of  us,  this  feature  was  common 
to  most  cases. 

A  study  of  the  pupils  and  of  the  fundus  of  the  eye  is  important 
and  liable  to  be  omitted  unless  the  physician  is  himself  familiar 
with  the  use  of  the  ophthalmoscope. 

Disturbances  of  speech  should  receive  careful  attention.  The 
interference  with  the  development  of  the  speech  center  is  not  so 
serious  a  defect  in  a  child  as  in  an  adult ;  for  in  them  the  corre- 
sponding hemisphere  may  take  on  and  develop  full  function. 

Aphasia  may  be  mental  or  physical,  or  due  to  defect  of 
the  organs  of  speech,  and  is  commonly  produced  by  adenoid 
growths  of  the  pharynx. 

Always  make  the  electric  examination  last,  because  a  child 
will  frequently  be  in  a  perfectly  good,  gentle  temper  until  the 
electricity  is  tried,  when  frequently  it  objects  and  becomes  un- 
manageable, and  it  is  impossible  to  secure  the  clinical  findings. 

The  knee-jerk  is  a  variable  phenomenon  in  children,  though 


THE    NEURON.  499 

readily  elicited  by  careful  methods.  It  is  easily  exhausted  by 
repeated  blows,  and  disappears  in  conditions  of  exhaustion.  It 
is  greatly  exaggerated  during  states  of  tension,  from  fear,  or 
struggling,  or  crying.  To  determine  its  significance,  studies 
must  be  made  at  different  times.  Ankle-clonus  does  not  occur 
in  the  very  young.  Contractions  are  almost  certainly  evidences 
of  organic  disease. 

The  Babinski  reflex  (see  p.  503)  is  normal  in  the  very  young, 
although  the  dividing-line  has  not  yet  been  determined. 

THE   NEURON. 

Waldeyer  gave  the  name  neuron  to  the  nerve-cell  as  a  unit. 
The  concept  of  the  neuron  theory,  as  held  by  many  neurologists 
and  anatomists,  but  disclaimed  by  others,  is  here  presented  to 
enable  the  student  to  get  a  clear  idea  of  the  very  fascinating 
views  which  it  embodies  and  suggests.  A  neuron  consists  of 
three  essential  parts,  the  first  of  which  is  the  nerve-cell,  as 
formerly  described.  An  example  is  the  cell  of  the  anterior  cornua 
of  the  spinal  cord.  This  cell  has  many  processes  and  two  func- 
tions, the  first  of  which  is  to  receive  impulses  and  the  second  is 
to  pass  them  on.  The  cell  receives  its  impulses  from  a  number 
of  protoplasmic  processes  which  divide  and  subdivide  into  a  fine 
meshwork  of  fibers  called  "  dendrons,"  which  may  be  regarded 
as  the  second  part  of  the  neuron.  These  dendrons  convey  im- 
pulses to  the  cell  and  are  described  as  cellulipetal  in  function. 
The  third  part  of  the  neuron  is  a  slender,  straight  process  which 
leaves  the  cell  in  much  the  same  manner  as  do  the  dendrons,  but, 
unlike  them,  does  not  divide.  It  sends  off  fine  side-shoots  which 
are  called  collaterals,  which  are  in  all  probability  associational  in 
function.  This  slender  fiber  is  the  axis-cylinder  and  is  efferent 
in  function,  being  spoken  of  as  cellulifugal. 

The  axis-cylinder  passes  to  its  destination,  which  is  either  the 
dendrons  of  another  nerve-cell  or  the  specialized  cells  in  a  muscle. 
In  the  latter  case  it  proceeds  to  the  muscle,  in  company  with 
many  other  axis-cylinders,  in  the  form  of  a  nerve,  and  when 
it  has  reached  its  destination,  breaks  up  into  a  fine  arborization 
around  an  end-plate. 

Before  speaking  of  the  manner  in  which  the  axis-cylinder  ends 
in  the  dendrons  of  another  neuron,  it  will  be  necessary  to  state 
briefly  the  neuron  theory. 

In  the  cortex  of  the  Rolandic  area  of  the  brain  there  are 
goodly  sized  nerve-cells  whose  axis-cylinders  or  neuraxons  pass 
down  through  the  internal  capsule  and  pons  into  the  pyramidal 


5OO  DISEASES    OF    THE    NERVOUS    SYSTEM. 

tract  of  the  medulla.  In  the  medulla  they  decussate  and  pass 
more  dorsolaterally  down  the  cord  as  the  crossed  pyramidal  tract. 
If  such  a  cell  is  located  in  the  arm  area  of  the  left  side,  by  the 
time  its  axis-cylinder  has  reached  the  cervical  enlargement,  being 
then  on  the  right  side,  it  passes  to  the  interior  horn  of  the  gray 
matter  and  breaks  up  into  a  fine  basketwork  of  fibrils  in  close  jux- 
taposition to,  but  not  joining  or  anastomosing  with,  the  dendrons 
of  the  anterior  cornual  cells.  We  speak  of  these  cortical  motor 
neurons  as  forming  the  upper  segment,  and  the  neuron  of  the 
anterior  cornual  cell  as  being  the  lower  segment  of  the  motor 
tract.  The  impulse  is  transmitted  simply  by  contact  and  not  by 
anastomosis. 

It  will  be  seen  that  the  upper  segment  is  a  crossed  tract,  and  the 
lower  segment  is  a  direct  one.  So  much  for  the  motor  neurons. 

The  lower  sensory  neuron  has  the  cell  in  the  ganglion  of  the 
posterior  roots  and  its  dendron  running  from  the  periphery  to  it. 
Its  neuraxon  enters  the  cord  by  the  posterior  root  and  divides 
into  two  portions — one  ascending  and  one  descending.  The 
ascending  portion  passes  up  the  same  side  of  the  cord  into  the 
medulla,  ending  in  the  posterior  nuclei  of  the  same  side.  The 
lower  sensory  segment  is,  therefore,  a  direct  tract.  The  descend- 
ing portion  of  the  neuraxon  from  the  posterior  ganglion  ends  in 
the  gray  matter  of  the  same  side  of  the  cord,  and  possibly  plays 
a  large  part  in  reflex  production.  The  upper  sensory  segment 
starts  in  the  posterior  nuclei,  and  decussates  at  once  the  neu- 
raxons,  passing  to  the  cortex.  Exactly  where  the  neuraxons  of 
the  upper  sensory  segment  end  is  not  determined,  but  it  is  sup- 
posed that  they  too  end  in  the  Rolandic  area,  this  area  being 
sensorimotor  in  function.  The  upper  sensory  segment  is  a 
crossed  tract. 


REFLEXES— THEIR    PHYSIOLOGY    AND 
SIGNIFICANCE. 

The  reflex  act  consists  in  an  afferent  impulse  carried  centrip- 
etally  along  an  afferent  nerve  which  is  purely  sensory  or  mixed  ; 
and  of  a  center  in  the  spinal  cord  for  the  spinal  nerves,  or  cer- 
tain centers  at  the  base  of  the  brain  in  the  case  of  the  cranial 
nerves.  Then  there  is  normally  the  efferent  impulse  passing  cen- 
trifugally  from  the  center  along  a  purely  motor  or  by  the  motor 
fibers  of  a  mixed  nerve. 

The  physiologic  cycle  is  termed  a  reflex  arc,  and  must  be 
intact  anatomically  and  functionally  to  permit  the  reflex  act  to 
pass  normallv  along  it,  which,  in  working  harmony,  constitutes 


REFLEXES.  5<DI 

the  major  part  of  the  functionation  of  the  new-born  infant ; 
hence  the  reflex  phenomenon  in  children  sustains  an  important 
relation  to  their  vital  actions,  and  this  gradually  lessens  in  activ- 
ity as  the  brain  develops  and  the  concept  and  precept  centers 
become  established. 

The  reflexes  may  be  divided,  clinically,  in  children  into  : 

1.  Somatic,  or  those  related  to  the  bodily  organs,  as  in  the 
vesical  reflex  controlling  urination  ;  the  sucking  reflex  sustaining 
pretty  much  the  entire  distribution  of  energy  which  causes  the 
infant  to  acquire  nourishment  from  the  breast ;  and  the  respira- 
tory reflex,  as  instanced,  for  example,  in  the  dyspnea  which  first 
excites  the  act  of  breathing  after  the  infant  is  brought  into  the 
external  air.     A  number  of  these  somatic  reflexes  are  of  essen- 
tial importance  in  the  development  of  the  child,  and  especially 
do  these  sensorimotor  activities  play  a   vital  role  in  nutrition, 
respiration,  etc. 

2.  The  skin  or   superficial   reflexes  are    those  sensorimotor 
phenomena  which  arise  from  a  stimulation  of  the  nerves  of  the 
skin,  and   are  divided  variously  into  the  orbicularis,  epigastric, 
abdominal,  cremasteric,  etc.,   according  to  the  topographic  dis- 
tribution  of  the   nerve -fibers  entering  into  the  particular  reflex 
arc.     These  reflexes  may  be  exhibited  by  a  gentle   irritation  of 
the  skin — examples,  cremasteric,  abdominal,  etc. 

3.  The  deep  or  muscle  reflexes  are  those  in  which  the  reflex 
arc  lies  at  its  distal  end,  further  away  from  the  surface  of  the 
body  than  those  of  the  skin,  and  require  a  firm  impact  of  the 
external  stimulus  (such  as  a  blow  upon  the  ligamentum  patellae) 
to  develop  them.      Contraction  of  the  masseter  muscle  of  the 
lower  jaw,  brought  out  by  striking  down  upon  the  mental  pro- 
cess of  the  inferior  maxilla  when  the  mouth  remains  passively 
open,  is  designated  the  chin  reflex.     The  motor  impulse  causes 
contraction  of  the  masseter  muscles,  and  hence  there  follows  a 
quick,  jerky,  partial  closing  of  the  mouth.     Other  deep  reflexes 
are  the  elbow-jerk,  the  knee-jerk,  the  ankle-jerk,  and  the  crossed 
reflex   or  contralateral  adductor  spasm,  etc.,  all   more  or  less 
familiar  to  the  student. 

4.  The  concept  reflexes  are  those  caused  by  thought,  and  have 
no  true  arc,  but  are  afferent  only  :  as,  for  example,  the  contrac- 
tion of  the  pupil  in  accommodation. 

The  so-called  muscle-jerk  is  merely  a  deep  reflex  brought  out 
by  tapping  directly  over  the  belly  of  the  muscle,  as  exhibited 
readily  on  the  biceps  of  the  arm,  and  produces  a  contraction  or 
humping  of  a  limited  portion  of  that  particular  muscle. 


5O2  DISEASES  OF  THE  NERVOUS  SYSTEM. 

MODIFICATION  OF  REFLEXES. 

As  to  the  modification  of  reflexes  in  health  or  disease,  it  will 
be  seen  at  a  glance  at  this  diagram  that  anything  which  cuts  off, 
stimulates,  or  inhibits  action  or  fibers  at  any  point  along  the  arc 
will  thus  affect  the  reflex  involved.  This  will  be  shown  as  we 
proceed.  It  must  be  remembered  that  the  brain  acts  as  the 
normal  inhibitor  of  all  reflexes. 

As  indicated  above,  the  child  is  influenced  in  growth  and 
development  most  largely  through  reflex  action,  and  it  is  at  all 
times  more  sensitive  than  is  the  adult,  whose  nerve  protoplasm 
has  become  matured  and  whose  neurons  have  become  more 
stable.  Inhibition,  abolition,  increased,  excessive,  spastic,  and 
tetanic  are  terms  descriptive  of  modification  of  reflexes. 

SIGNIFICANCE  OF  THE  REFLEXES. 

The  significance  of  the  reflexes  in  childhood  is,  therefore, 
shown  to  be  of  the  utmost  significance  and  importance.  The 
variation  and  vacillation  of  cell  activity  in  early  life  are  to  be 
always  borne  in  mind.  By  a  study  of  large  numbers  of  healthy 
and  of  abnormal  children  the  full  clinical  significance  of  the 
various  reflex  acts  can  be  estimated.  Then  the  factors  of 
heredity  and  inheritance  must  be  carefully  weighed  before  an 
opinion  can  be  formed  of  the  quality  and  significance  of  the  reflex 
phenomena  in  childhood.  Hence,  while  we  note  the  intricacy  of 
the  problem,  it  can  only  be  solved  by  a  fair  knowledge  of  the 
physiology,  etc.,  and  the  personal  factor  of  the  observer,  but  it 
is  always  important  for  the  attending  physician  to  note  the  con- 
ditions found,  which  will  serve  as  valuable  data  for  the  use  of  the 
consultant  who  may  be  called  upon  to  give  an  opinion  in  difficult 
cases. 

EXCESS  OF  REFLEX  ACTION. 

Cerebral. — In  mental  diseases  of  active  type,  as  in  mania,  the 
reflexes  are  increased.  If  there  is  a  generalized  increase  of  the 
skin  and  deep  reflexes,  but  not  to  the  degree  of  spasticity,  it  is 
significant  of  a  central  irritation,  whether  it  be  from  a  cerebritis, 
meningitis,  or  a  pressure  from  subarachnoid  effusion  or  the  like. 
If  the  irritation  continues  or  increases,  there  are  liable  to  follow 
convulsions,  local  or  general,  followed,  it  may  be,  by  palsies, 
transient  or  permanent.  If  recovery  ensues,  a  spastic  condition 
of  the  limb  may  remain,  with  the  development  of  adventitious 
reflexes  (as  ankle-clonus)  and,  still  later,  contractures  which  may 
demand  surgical  help  by  tenotomies,  etc.  Passive  motion  and 


REFLEXES.  503 

other  well-directed  manipulations  benefit  these,  not  over  the  limb, 
but  the  center  thus  affected.  A  complete  freeing  of  the  controlled 
tendons  by  either  of  these  means  benefits  the  whole  affected 
region  or  tract.  This  is  abundantly  illustrated  in  the  case  of 
sufferers  from  cerebral  diplegias  in  whom  the  cerebration  is  also 
improved  by  mechanical  measures.  An  excess  of  cortical  pres- 
sure will  lessen  or  obliterate  reflex  action  by  obtunding  the  con- 
ductibility  of  nerve-fibers.  In  chronic  hemiplegias  increase  in 
reflex  activities,  with  ankle-clonus,  occurs  on  the  affected  side. 
In  tetanus,  hydrophobia,  transverse  myelitis,  and  insular  sclerosis 
the  exaggeration  of  the  superficial  and  deep  reflexes  is  asso- 
ciated with  the  other  symptoms  of  these  diseases. 

Spinal. — Increase  of  reflexes  due  to  lesions  of  spinal  origin 
is  to  be  differentiated  by  excluding  the  semeiology  of  cerebral 
disorders  and  by  including  all  signs  of  spinal  disease. 

Lateral  sclerosis  is  the  rare  form  occurring  in  childhood  and 
causes  spastic  reflexes,  especially  in  the  lower  extremities,  but 
may  extend  to  the  arms  or  even  to  the  head  and  neck.  In  this 
case  athetoid  movements  of  the  hands  or  nystagmus  would  be 
likely  to  supervene,  signifying  a  disseminated  sclerosis  and  the 
resulting:  irritation  which  has  occurred. 


DIMINUTION  OF  REFLEX  ACTION  (SENSORIMOTOR). 

Cerebral. — In  apathetic  mental  disease  (melancholia)  the  re- 
flexes are  lessened.  As  stated  above,  extreme  pressure  within  the 
cranial  cavity,  or  within  the  spinal  canal,  will  lessen  or  cut  off 
the  reflex  act.  In  degeneration  of  muscles  or  nerves  from  inhe- 
rent disease  or  from  disease  of  the  contingent  peripheral  neurons, 
as  shown  by  the  reversal  of  the  galvanic  formula  (reaction  of 
degeneration),  the  reflexes  are  greatly  lessened  or  abolished. 
Therefore,  to  mention  specific  diseases,  such  as  chronic  myelitis 
with  complete  degeneration  of  the  cord  or  of  the  sensory  or 
motor  roots  of  the  spinal  cord,  the  reflexes  below  the  site  of 
lesion  are  lessened  or  wanting.  In  the  purely  motor  sphere  we 
have  the  reflex  wanting  in  anterior  poliomyelitis,  in  paralysis  of 
a  motor  nerve,  and  in  the  muscle  dystrophies  and  in  neuritis. 

In  the  sensoiy  sphere  in  childhood  we  have  the  reflex  lessened 
or  absent  in  hereditary  ataxia  or  in  the  rare  precocious  true  pos- 
terior spinal  sclerosis,  and  in  injury  of  a  sensory  nerve,  in  which 
case  anesthesia  will  follow,  or  in  neuritis  of  a  mixed  nerve,  when 
also  motor  palsy  will  be  a  symptom  present. 

Some  terms  used  in  regard  to  reflexes  as  a  whole : 

"  Babinski's  sign  "  is  an  extension  of  the  toes,  when  the  role 


504  DISEASES    OF   THE    NERVOUS    SYSTEM. 

of  the  foot  is  imitated,  rather  than  the  normal  flexion  of  them — . 
supposed  to  be  indicative  of  disease  of  the  pyramidal  tracts. 
This  new  sign  has  not  been  accepted  by  many  writers. 

The  muscular  sense  is  the  reflex  Which  causes  appreciation 
of  size  and  position  and  the  combined  movements  of  a  whole  or 
part  of  the  body. 

Inhibition  of  a  reflex  refers  to  lessening  of  the  reflex  act. 

A  capricious  reflex  is  one  that  is  not  constant  in  response  to 
stimuli. 

Reinforcement  of  a  reflex  implies  a  quickening  or  an  increase 
in  the  rapidity  or  range  of  the  reflex  act,  and  is  due  to  impulse 
given  by  a  simultaneous  motor  act,  as  in  "making  a  fist,"  or  in 
concept,  reinforcement,  as  by  thinking  intently  upon  some  sub- 
ject at  the  time  the  reflex  is  brought  out 

MOTOR  EXCITEMENTS. 

Disturbances  of  motion,  where  movement  is  in  excess  and 
more  or  less  beyond  control,  are  called  convulsions,  spasms, 
choreic  movements,  tremors,  and  automatic  movements. 

Local  spasms  may  occur  as  disturbances  of  motion  in  the 
muscles  of  organic  life,  such  as  esophageal,  rectal,  urethral,  and 
the  like.  Vomiting  is  a  local  spasm  ;  so  are  certain  forms  of 
nervous  cough.  Spasms  of  voluntary  muscles  produce  such 
effects  as  laryngismus  stridulus,  child-crowing,  and  the  like. 

Tremors  may  be  choreic,  hysteric,  and  that  form  seen  in  habit 
chorea,  as  well  as  due  to  organic  disease.  Choreiform  move- 
ments may  be  local  as  well  as  general.  Automatic  movements 
are  of  rather  wide  variety,  due  to  hysteria,  habit  chorea,  and 
such  like  disturbances,  partly  organic  and  mostly  functional, 
occurring  sometimes  in  epidemics. 

CONVULSIONS. 

A  convulsion  is  a  temporary  overflow  of  motor  impulses,  pro- 
ducing purposeless  muscular  contractions,  alternating  with  re- 
laxations for  shorter  or  longer  periods,  attended  by  more  or  less 
loss  of  consciousness.  If  the  alterations  are  rapid,  the  form  is 
called  clonic  ;  if  slow,  the  contractions  being  maintained  for  a 
variable  time,  it  is  called  tonic.  A  spasm  is  a  more  or  less 
rapidly  alternating  contraction  and  relaxation  of  certain  muscles 
or  groups  of  muscles  affecting  a  limited  portion  of  the  body  ;  it 
is  essentially  local,  and,  as  a  rule,  does  not  involve  the  centers 
nor  disturb  consciousness.  A  tremor  is  a  rapid  rhythmic  vibra- 


CONVULSIONS.  505 

tion  in  the  muscles.  Convulsions  may  be  epileptiform,  hysteroid, 
or  tetanic.  In  epileptic  and  hysteroid  convulsions  consciousness 
is  disturbed  because  these  emanate  from  the  brain  centers.  In 
the  tetanic  form  this  is  peripheral,  and  not  central.  In  epileptic 
convulsions  consciousness  is  lost  or  severely  imparied,  as  a  rule. 
In  hysteria  this  is  also  true  at  times,  wholly  or  in  part,  but  is 
not  to  be  expected.  Local  spasms  may  occur  as  disturbances  of 
motion  in  the  muscles  of  the  vital  organs,  such  as  esophageal, 
rectal,  urethral,  and  the  like.  Vomiting  is  a  local  spasm  ;  so  are 
certain  forms  of  nervous  cough.  Spasms  of  voluntary  muscles 
in  young  children  produce  such  alarming  effects  as  laryngeal 
spasm,  or  laryngismus  stridulus,  child-crowing,  and  the  like. 

Automatic  movements  are  irregular,  involuntary  muscular 
acts,  more  or  less  coordinated,  and  simulating  voluntary  acts. 

INFANTILE  CONVULSIONS. 

Convulsions  occurring  in  young  children  constitute  a  symptom, 
not  a  disease.  They  vary  widely  in  severity,  beginning  locally 
and  becoming  general,  or  they  may  prove  to  be  overwhelming 
motor  discharges  so  intense  as  to  cause  serious  disablement  or 
possible  death.  Modern  writers  deny  the  gravity  of  infantile 
convulsions,  so  far  as  immediate  results  are  concerned,  but 
readily  admit  that  very  grave  subsequent  effects  often  follow. 

Symptoms. — Almost  anyone  of  moderate  intelligence  will 
readily  recognize  a  well-marked  convulsion  or  even  a  convulsive 
tendency  ;  but  it  is  of  the  utmost  importance  that  the  first 
observer  shall  carefully  note  and  be  able  to  relate  accurately  the 
starting-point  and  phenomena  of  progress,  the  degree  of  severity, 
and  the  length  of  time  it  has  persisted.  On  these  facts  will 
depend  a  proper  diagnosis  of  the  character  and  seat  of  the  irri- 
tation. The  slightest  twitching  of  the  thumb  may  indicate  irri- 
tation or  disease  near  the  thumb  center.  So  twitchings  of  the 
eyelid  or  movements  in  and  around  the  corners  of  the  mouth 
point  to  central  disease.  Unilateral  convulsions  do  not  neces- 
sarily indicate  a  local  lesion,  although  they  form  a  fair  ground  for 
suspicion  of  focal  disease.  There  is  usually  some  prodromal 
symptom,  more  or  less  brief,  such  as  slight  twitchings,  alluded  to 
in  the  muscles  of  the  extremities  or  face,  a  general  restlessness, 
and  startings  upon  slight  irritation  from  touch  or  noises.  Im- 
mediately before  the  convulsion  there  is  often  pallor,  a  fixity  of 
the  eyes,  or  they  may  be  rolled  up  into  their  orbits  ;  these 
slight,  isolated  movements  may  pass  into  convulsive  twitchings, 
extending  rapidly  over  the  entire  body,  or  shifting  from  one  side 


5O6  DISEASES    OF    THE    NERVOUS    SYSTEM. 

to  another,  or  from  one  limb  to  the  opposite  one,  along  with,  or 
alternating  with,  movements  in  the  face  or  head,  retraction  of  the 
head,  or  rolling  of  the  body  over  to  one  side  or  the  other. 

A  succession  of  grimaces  due  to  contraction  of  the  facial  mus- 
cles may  be  the  only  early  change  seen,  or,  later,  the  hands  may 
be  clenched,  the  thumbs  being  buried  in  the  palms  ;  the  great  toe 
extended  downward — "  carpopedal  spasms" — or  these  phe- 
nomena again  may  be  followed  by  a  general  commotion,  frothing 
at  the  mouth,  disturbed  respiration  and  pulse,  slow  or  rapid, 
usually  irregular,  sweating  of  the  forehead,  and  blueness  of  the 
lips  and  face.  The  sphincters  may  become  relaxed,  urine  and 
feces  being  passed  involuntarily.  After  the  fit  there  is  usually 
evidence  of  prostration,  and  temporary  palsies  not  infrequently 
follow,  due  to  exhaustion  of  the  nerve  centers.  One  attack  of 
convulsions  is  commonly  followed  by  others,  exhibiting  an 
increasing  susceptibility.  Convulsions  coming  on  in  a  child  pre- 
viously well  point  to  some  acute  disease  of  exceptional  severity,  or 
possibly  acute  meningitis.  Convulsions  occurring  in  most  forms 
of  brain  disease  are  not  usually  accompanied  by  marked  tem- 
perature rises,  but  are  liable  to  exhibit  pupillary  changes, 
strabismus,  rigidity,  or  localized  palsies. 

Causes. — Convulsions,  local  or  general,  arise  in  excessive  and 
irregular  discharges  of  nerve  centers  in  the  cortex  or  base  of 
the  brain.  Nothnagel  suggests  a  convulsive  center  in  the  pons. 

Experiments  by  Suschtschinski  and  Wyrubow  have  shown 
that  the  convulsions  caused  by  irritation  of  the  pons  are  not  the 
effects  upon  a  convulsion  center,  but  due  to  the  transmission  of 
irritation  to  the  cerebral  hemispheres  and  especially  the  motor 
cortex. 

The  seat  of  discharge  in  convulsions  is  presumably  in  the 
ganglion  cells  of  the  brain,  and  the  molecular  disturbances  in 
these  cells  necessary  to  the  morbid  discharge  are  determined 
either  by  direct  irritation  of  those  centers  or  reflexly  through 
peripheral  irritation.  The  phenomena  have  to  do  with  exalta- 
tion of  the  lower  centers  or  loss  of  inhibition  in  the  higher 
centers,  or  both. 

In  infants  the  nervous  system  is  structurally  immature,  but  in 
process  of  rapid  development.  Even  after  structural  completion 
time  is  required  to  attain  functional  stability. 

At  birth  the  lower  centers  only  are  developed  ;  hence  control 
is  limited  until  the  higher  centers  become  competent  to  exert 
inhibition.  In  the  earlier  months  of  life  convulsions  are  com- 
mon, progressively  less  so  after  birth  to  the  first  year  of  life 
(Kassowitz),  and  are  rarer  after  the  second  year. 


CONVULSIONS^  -07 

'^ff.fr.'     r^?/>w 
It  is  unusual,  perhaps  impossible,  for  a  healthy  child  to  suffer 

from  convulsions  unless  the  exciting  cause  be  overwhelming, 
such  as  trauma,  an  intense  irritant,  or  poison.  Convulsions 
readily  occur  in  children  of  unstable  equilibrium.  This  dan- 
gerous condition  may  arise  from  inheritance  or  become  acquired, 
and  is  of  very  varying  degree.  One  convulsion  predisposes  to 
another,  and  the  habit  may  become  fixed. 

Some  families  are  especially  prone  to  suffer  ill  effects  from 
motor  excitements,  or  their  infants  offer  but  feeble  resistance  to 
excitants,  be  these  physical  or  psychic.  Again,  individuals  vary 
from  time  to  time,  and  are  rendered  susceptible  by  depressing 
causes,  nutritional  and  emotional,  as  well  as  by  the  onset  of 
definite  disease. 

Exciting  causes  are  chiefly  reflex  from  peripheral  irritations, 
inducing  overactivity  in  convulsive  centers.  The  history  of  many 
of  these  must  be  received  with  caution,  since  deeper  causes  can 
usually  be  found  where  careful  search  is  made,  more  probably 
several  causes  acting  together :  vasomotor  instability,  temporary 
or  prolonged ;  states  of  anemia ;  variations  in  blood  supply  and 
quality,  along  with  states  of  certain  special  nerve  irritation,  as 
that  of  the  fifth  or  of  the  gastro-intestinal  supply,  and  the  ex- 
tremes of  heat  and  cold  and  rickets,  produce  conditions  which 
react  in  convulsions  from  relatively  slight  exciting  causes. 

What  part  is  actually  played  by  disordered  dentition  is  not 
determined,  but  the  weight  of  modern  evidence  is  against  this 
being  of  great  significance.  Some  go  so  far  as  to  assert  that 
it  is  absolutely  nil ;  others  admit  that  it  exerts  some  positive 
influence.  Certainly  it  is  not  shown  to  be  a  large  factor.  The 
lancing  of  the  gum  over  an  approaching  tooth  often  relieves  the 
spasm.  In  the  same  category  of  doubtful  causes  may  be  men- 
tioned the  presence  of  intestinal  parasites,  where  removal  is, 
however,  of  practical  value. 

Of  the  determining  causes,  by  far  the  most  important  is  the 
use  of  improper  food,  unsuited  in  amount,  kind,  or  condition  to 
the  needs  of  the  young  child.  This  acts  often  as  both  funda- 
mental and  exciting  cause.  Milk  from  a  mother  or  wet-nurse 
may  be  vitiated  by  various  causes, — fatigue,  emotional, — or  it 
may  act  as  a  medium  of  poisons, — such  as  alcohol, — and  has 
been  known  to  thus  cause  convulsions. 

Other  determining  causes  besides  the  visceral  sensory  distribu- 
tion (gastro-intestinal)  are  such  as  disordered  dentition  (fifth 
nerve) ;  the  various  infections,  especially  whooping-cough, 
syphilis,  scarlatina,  and  the  other  exanthemata  ;  ptomains  and 
leukomains,  uremia,  malaria,  heat,  cold,  febrile  states,  burns, 


0\  \  .N 

w\e- 

C.O&  DISEASES    OF    THE    NERVOUS    SYSTEM. 

^vr         ,\ 
Lp\c . 

fatigue  and  depressing  influences,  blood  loss,  shock,  emotions, 
fright,  anger,  etc.  Of  poisons,  some  are  the  toxins  generated 
within  the  organism  alluded  to,  and  others  are  swallowed,  among 
which  should  be  borne  in  mind  lead,  alcohol,  etc. 

Interesting  cases  were  reported  byD.  D.  Stewart  among  a  ser- 
ies of  children  poisoned  by  lead  used  as  coloring-matter  in  cakes. 
Meunier  reports  cases  of  convulsions  caused  by  breast-milk  where 
the  nurse  took  large  amounts  of  alcohol.  Many  of  these  cases  are 
aggravated  by  meteorologic  conditions,  especially  of  hot  weather 
in  summer.  It  has  long  been  believed  that  convulsions  fre- 
quently occur  as  a  prodrome  in  pneumonia,  but  Gossage  and 
Coutts  show  a  series  of  166  cases  with  this  symptom  in  only  8, 
or  4.7  per  cent. 

Convulsions — and  these  the  more  serious  ones — are  also  due 
to  various  forms  of  cerebral  disease  :  hemorrhage,  internal  pres- 
sure, as  from  rapidly  increasing  hydrocephalus  or  abscess,  and 
emboli  and  thrombosis,  and,  above  all,  rickets.  Only  a  small 
proportion  of  cases  of  convulsions,  however,  are  demonstrated  to 
occur  in  children  who  have  evidences  of  rickets.  In  them  motor 
disorders  are  more  likely  to  be  tetany  and  laryngospasm.  The 
brain  presumably  suffers  from  malnutrition  in  all  these  disorders, 
and  to  this  the  instability  is  due. 

Prognosis. — In  estimating  the  dangers  resulting  from  convul- 
sions it  is  necessary  to  consider  the  nature  and  extent  of  the 
cause.  In  children  of  a  markedly  unstable  nervous  equilibrium 
a  convulsion  may  mean  little  or  nothing.  Moreover,  moderate 
convulsions  occurring  in  young  infants  are  of  small  import.  Fits 
appearing  as  prodromes  of  acute  febrile  diseases  are  rarely  serious, 
and  may  not  even  indicate  an  unusually  severe  attack  of  the  dis- 
ease. When  they  occur  after  the  establishment  of  the  character- 
istic features  of  the  disease,  they  are  of  deeper  significance,  and 
may  indicate  the  oncoming  of  nephritis,  meningitis,  or  other 
grave  complications.  Those  points  on  which  one  is  likely  to 
base  a  serious  prognosis  are  extreme  prolongation  and  frequent 
recurrence  of  the  convulsions  ;  also  profound  disturbances  of  the 
circulation,  stupor,  or  subsequent  prostration. 

Gossage  and  Coutts  lay  great  stress  on  the  facts  that  the  dan- 
ger of  future  neurotic  manifestations  in  children  who  have  had 
convulsions  has  been  much  underestimated  ;  predisposing  are 
of  more  importance  than  the  exciting  causes  ;  and  that  the  slighter 
exciting  causes  will  not  produce  convulsions  except  in  children 
so  predisposed.  Statistics  were  produced  at  the  1899  meeting 
of  the  British  Medical  Association,  showing  that  over  one-half 
of  the  patients  who  had  exhibited  convulsions  in  infancy  were 


CONVULSIONS.  509 

found  to  suffer  from  some  form  of  neurosis.  And  these  were  not 
so  much  to  be  ascribed  to  the  malnutrition  of  the  nervous  system 
in  infancy  or  to  damage  during  the  convulsive  stage  as  to  con- 
genital faulty  development.  This  is  particularly  true  in  children 
of  gouty,  nervous,  rheumatic,  or  diabetic  parents,  and  it  is  among 
those  in  whom  such  a  diathesis  is  known  to  exist  that  any  ex- 
treme of  reflex  irritation  must  be  repressed  or  it  will  result  in  a 
nervous  explosion. 

Treatment. — The  treatment  of  convulsions  divides  itself  in 
two  very  unequal  parts  :  to  overcome  the  symptom  and  to  mas- 
ter the  underlying  condition.  The  indications,  for  the  first,  are  to 
hasten  to  the  case  with  all  speed,  to  secure  promptly  various 
items  of  equipment,  which  ma'y,  any  or  all,  be  needed,  but  the 
absence  of  any  one  of  which  may  cause  serious  embarrassment, 
possibly  danger  to  life. 

A  severe  or  continued  condition  of  convulsions  may  produce 
serious  damage  to  remote  organs  and  tissues.  The  explosion 
may  be  overcome  by  the  inhalation  of  chloroform,  which,  in  the 
condition  of  such  a  state  of  nervous  exaltation,  is  quite  safe.  To 
this  may  be  added,  with  advantage,  nitrite  of  amyl  and  sulphuric 
ether.  The  mixture  we  have  used  for  years  most  successfully  in 
the  paroxysm  of  pertussis  is  equally  applicable  here  :  amyl  nitrite, 
one  dram  ;  spirits  of  chloroform,  three  drams  ;  sulphuric  ether, 
five  drams.  It  is  well  to  loosen  the  clothing,  or,  better,  to  re- 
move it  promptly.  Thus  many  important  points  may  be  revealed. 
Often  the  child  will  be  found  in  a  bath  of  hot  water ;  perhaps 
mustard  is  added.  In  the  excitement  this  may  have  been  so 
hot  or  irritating  as  to  cause  damage,  and  it  is  best  to  remove  the 
child  at  once,  and  it  may  be  necessary  to  investigate  the  condi- 
tion of  the  skin  and  apply  emollients.  If  not  in  a  bath,  it  is  often 
useful  to  apply  a  mustard  pack — which  consists  of  one  teaspoon- 
ful  of  dry  mustard  rubbed  up  with  one  ounce  of  water  and  added 
to  a  quart  of  hot  water,  and  into  this  a  sheet  or  bath-towel  is 
dipped  and  wrapped  around  the  child.-  After  this  has  been  ap- 
plied for  a  suitable  time,  or  during  the  continuance  of  it,  a  care- 
ful search  should  be  made  for  various  sources  of  reflex  irritation. 
The  chief  of  these  may  be  found  in  the  digestive  tract,  and  the 
next  routine  procedure  to  be  recommended  is  to  apply  a  cleansing 
enema.  This  enema  serves  several  valuable  ends  in  removing 
feces  or  undigested  food,  and,  if  hot,  aids  in  stimulating  capillary 
relaxation.  If  the  temperature  be  found  high,  this  can  be  fol- 
lowed, with  advantage,  by  a  cool  enema.  If  subnormal,  as  is 
the  case  frequently  in  the  convulsions  following  summer  diar- 
rheas, a  salt  enema  supplies  fluid  by  imbibition,  or  hypodermat- 


5IO  DISEASES    OF    THE    NERVOUS    SYSTEM. 

oclysis  may  be  even  better.  We  have  seen  lives  saved  by  this. 
In  hyperpyrexia  cold  to  the  head  is  in  most  cases  a  useful  measure. 
If  congestive  states  are  pronounced,  local  blood-letting  by  leeches 
is  of  much  use,  and  is  recommended  by  Baginsky  and  others.  If 
the  cause  is  due  to  intracranial  tension  or  acute  hydrocephalus, 
lumbar  puncture  is  a  useful  and  safe  measure,  and  this  we  have 
done  with  great  satisfaction  many  times.  Baginsky  recommends 
local  blood-letting  by  leeches,  especially  when  simple  convulsions 
resist  treatment  and  in  those  due  to  uremia.  If  the  convulsions 
be  unduly  prolonged,  the  use  of  morphin  hypodermically  is  both 
safe  and  gratifying.  If  the  first  dose  (of  say  -^  grain  to  a  six- 
months-old  baby)  is  not  sufficient,  a  second  may  be  given  in  an 
hour,  of  double  the  first  dose  (^  grain),  and  again,  in  an  hour, 
double  of  this  (y1^  grain)  if  needed,  or  until  quiet  is  secured. 

When  there  is  asphyxia  or  marked  cyanosis,  oxygen  is  a 
valuable  agent ;  this  is  best  administered  to  infants  through  a 
large  face-piece  and  one  straight  tube.  When  the  bowels  are 
sufficiently  cleared,  sedatives  can  be  administered  by  the  rectum  ; 
chloral  and  the  bromids  are  most  used.  For  a  six-months-old 
baby  four  grains  of  chloral  or  six  grains  of  bromid  of  sodium 
or  strontium,  one  or  both,  may  be  given  ;  for  a  baby"  of  one  year 
six  grains  of  chloral  and  ten  of  a  bromid  is  a  suitable  dose,  to 
be  repeated  again  at  hourly  intervals  if  needed.  Authorities 
differ  as  to  whether  an  emetic  should  be  employed  ;  but  if  there 
is  reason  to  believe  that  there  is  undigested  food  in  the  stomach, 
this  should  be  used  ;  and  while  there  may  be  theoretic  objections, 
we  have  no  reason  to  believe  that  harm  has  been  thus  caused. 
Emesis  in  children  is  so  readily  induced  that  there  need  be  little 
fear  of  injurious  effects  unless  excessive  stimulus  is  employed  by 
overdosing  with  emetics.  So  soon  as  the  child  can  swallow,  it 
is  well  to  give  a  grain  or  two  of  calomel,  which  acts  usefully  in 
several  ways,  even  if  it  does  not  purge.  To  produce  a  full 
laxation,  where  this  seems  necessary,  milk  of  magnesia,  castor 
oil,  or  some  other  active  drug  can  be  employed.  After  having 
instituted  these  measures  to  overcome  the  activity  of  the  con- 
vulsion, a  thorough  search  should  be  made  for  such  sources  of 
reflex  irritation  as  phimosis,  an  approaching  tooth,  foreign  bodies 
in  the  nose  or  ears,  etc.  As  soon  as  possible  the  history  of  the 
case  should  be  scrutinized  for  remoter  conditions,  such  as  the 
existence  of  a  pneumonia,  the  possibility  of  the  beginning  of  an 
exanthem,  etc.  It  must  be  borne  in  mind  that  the  occurrence  of 
convulsions  is  much  more  frequent  and  vastly  more  dangerous 
during  the  progress  than  at  the  beginning  of  either  pneumonias 
or  the  exanthemata.  If  they  arise  at  the  end  of  an  exhausting 


TETANY.  5  I  I 

disease,  as  of  those  two  just  mentioned,  or  of  a  prolonged 
diarrhea,  the  process  is  essentially  different  and  will  call  for  other 
measures.  If  the  urine  contains  albumin,  which  must  be  ascer- 
tained without  delay,  diaphoresis  is  important  ;  but  diuresis  must 
not  be  neglected,  and  here  repeated  injections  of  warm  salt  solu- 
tion through  the  bowel  is  of  value,  or  also  hypodermatoclysis. 
Among  the  acute  conditions  which  are  competent  to  produce 
convulsions  in  healthy  children  are  injuries  to  the  head,  which  are 
liable  to  be  followed  by  shock  and  are  to  be  treated  as  such  by 
external  heat,  cold  to  the  head,  and  stimulating  enemata.  Sun- 
stroke and  heat  exhaustion  call  for  appropriate  treatment  ;  in 
the  former,  external  cold  is  indicated,  and,  in  the  latter,  heat  and 
stimulants,  of  which  among  the  best  is  coffee.  An  accidental 
cause  may  be  mechanical  obstruction  of  the  upper  air-passages, 
and,  if  apnea  is  the  chief  difficulty,  the  introduction  of  a  tongue 
depressor,  drawing  the  tongue  firmly  down  and  forward,  may 
remove  the  symptom  almost  immediately.  Lastly,  it  must  not  be 
forgotten  that  convulsions  may  be  a  phenomenon  of  impending 
death,  when  it  is  impossible  to  expect  to  relieve  them  ;  although 
it  is  oftentimes  admissible  to  make  use  of  strychnin  hypodermically 
and  in  large  doses,  and  of  other  forms  of  stimulation. 

TABLE  OF  CAUSES  OF  INFANTILE  CONVULSIONS. — (From  T.  M.  Retch.} 
Central.  Peripheral  (Reflex). 

1.  Diseases  of  high  temperature  (isolation,  meningitis,       Rachitis. 

the  exanthemata,  pneumonia,  and  others).  Food. 

2.  Diseases  accompanied  by  vascular  stasis  (pertussis,        Intestinal  parasites. 

cardiac  diseases,  tumors,  hydrocephalus).  Dental  irritation. 

3.  Diseases  characterized  by  anemia  and  exhaustion       Foreign   bodies    in    the    ear 

(loss  of  blood,  diarrhea).  and  nose. 

4.  Various  toxic   causes,   such  as  drugs   or   uremia       Mot  baths. 

(belladonna,   nephritis).  Mental  disturbances,  such  as 

5.  Organic  central  lesions  (cerebral  paralysis  or  any  fright,  and  numerous  other 

other  lesions  of  the  brain).  causes. 

6.  Presumably  organic  disturbance  of  the  brain  (epi- 

lepsy). 

TETANY. 

Tetany  is  a  motor  neurosis  called  by  some  authorities  a  disease, 
but  is  more  generally  described  as  a  mere  disorder  based  upon 
several  pathologic  factors  which  are  more  or  less  constant.  It 
is  probably  of  toxic  origin,  and  bears  close  etiologic  relationship 
to  rickets,  being  based  upon  similar  causative  factors  and  sharing 
some  of  the  symptom  phases  of  that  disease.  It  is  far  from 
common,  yet  can  not  be  considered  rare,  and  is  much  more 
frequently  recognized  of  late  years,  since  its  entity  is  better 
known  and  clearly  described.  Tetany  is  manifested  by  charac- 


512  DISEASES    OF   THE    NERVOUS    SYSTEM. 

teristic  attitudes  of  the  hands  and  certain  intermittent  tonic 
cramps  of  the  muscles  of  the  arms  and  legs,  by  an  excessive 
electric  irritability,  and  by  periods  of  latency  during  which  the 
cramps  can  be  artificially  induced. 

Causes. — Tetany  arises  in  certain  localities,  and  is  not  seen 
again  for  long  periods.  It  may  become  epidemic  (Bruns).  The 
condition  was  described  by  Trousseau  originally,  who  discovered 
the  important  symptom  known  by  his  name — viz.,  that  an  attack 
could  be  induced  in  an  affected  subject  by  compressing  the 
arteries  and  the  nerve  trunks.  Tetany  occurs  in  both  adults  and 
children  in  about  equal  frequency  (B.  Sachs),  but  most  cases  are 
seen  in  the  very  young.  Holt  says  it  is  usually  seen  in  early 
infancy.  Barthez  and  Sanne  found  it  more  often  in  children  and 
most  in  infants.  Griffith  found  66  per  cent,  under  two  years 
of  age. 

The  disorder  is  much  more  common  among  the  children  of 
the  lower  classes,  and  those  whose  surroundings  are  unwhole- 
some. It  almost  always  follows  upon  depressing  conditions, 
overexertion,  or  recognizable  disorders  or  diseases,  especially  the 
transmissible  ones  ;  hence  its  pathology  is  regarded  as  a  toxemia 
of  probably  a  complex  sort,  or  perhaps  a  mere  neurosis.  It  is 
frequently  associated  with  rickets.  Rarely  it  has  resulted  from 
a  known  poison,  such  as  lead,  alcohol,  or  ergot.  It  occurs  as  a 
finality  to,  or  is  associated  with,  structural  diseases  of  the  nerves, 
and  is  known  to  result  from  extirpation  of  the  thyroid  gland. 
That  the  thyroid  gland  secretes  a  something,  the  absence  or 
excess  of  which  is  followed  by  a  perturbation  of  the  normal 
nervous  balance,  is  a  fascinating  view,  of  which  Ewald  makes  a 
strong  point.  Weiss  pointed  out  the  connection  between  these 
toxins  and  tetany.  That  intestinal  parasites  secrete  a  peculiarly 
disturbing  toxin  is  urged  by  Albu  and  others.  Maestro  advocates 
the  administration  of  extract  of  thyroid  gland,  and  exhibits  clin- 
ical findings  from  the  measure  which  are  convincing  ;  and  in  this 
S.  S.  Adams  follows  him  confidently.  Tetany  was  at  one  time 
regarded  as  an  occupation  neurosis,  but  Kussmaul  corrected  this 
view.  Any  exhausting  disease  is  a  possible  cause  of  tetany  in 
those  predisposed  to  this  form  of  motor  disturbance.  The  con- 
nection of  the  disease  with  rickets  is  still  a  topic  for  discussion. 

The  etiology  of  tetany  in  childhood  is  riot  clear.  It  never 
affects  healthy  children.  Rachitis  is  of  important  predisposing 
influence.  The  direct  cause  of  the  attack  is  some  gastro-intestinal 
disturbance,  proved  by  the  frequent  association  of  tetany  and 
acute  dyspepsia,  and  the  effect  of  treatment  directed  to  such 
conditions  (Hauser). 


TETANY.  5  I  3 

Symptoms. — The  symptoms  of  tetany  are  to  be  divided  into 
those  of  the  attack  and  those  of  the  period  of  latency.  The 
onset  of  the  paroxysms  may  be  preceded  by  sensory  phe- 
nomena, but  is  often  sudden  and  without  warning.  The  sensa- 
tions are  usually  vague  tingling  pains  in  the  forearms  and  legs, 
followed  soon  by  a  tonic  spasm  or  a  stiffness  in  the  muscles. 
This  spasm  is  most  marked  in  the  upper  extremities,  giving  rise 
to  such  a  pronounced  rigidity  that  it  is  almost  impossible  to 
overcome  the  resistance  by  active  effort  on  the  part  of  an- 
other. Occasionally  the  adductors  of  the  thighs  and  arms  are 
involved,  causing  the  arms  and  legs  to  be  drawn  together  ;  more 
rarely  the  muscles  of  the  neck  are  involved,  and  also  those  of 
the  face  and  trunk.  Morse  says  the  only  true  pathognomonic 
symptom  is  spontaneous  intermittent  paroxysmal  muscular  con- 
tractions. The  most  common  seat  of  these  contractures  is  in 
the  muscles  of  the  forearms,  the  fingers  being  flexed  at  the 
metacarpophalangeal  joints,  while  the  phalanges  are  extended, 
the  thumbs  being  strongly  adducted,  the  wrists  acutely  flexed, 
and  the  hands  turned  to  the  ulhar  side.  The  position  of  the 
hand  is  called  the  "  accoucher's  hand  "  or  the  "  writing  hand." 
Other  attitudes  are,  however,  occasionally  seen,  such  as  a  firm 
clutching  or  even  complete  extension  of  the  fingers.  The  fore- 
arm may  be  flexed  upon  the  arm,  the  arm  adducted  to  the 
shoulder. 

If  the  lower  extremities  are  involved,  the  thighs  may  be 
adducted,  the  legs  extended  or  flexed ;  the  toes  are  apt  to 
assume  the  position  of  talipes  equinus.  The  spasms  may  affect 
the  muscles  of  the  abdomen,  the  back,  the  diaphragm,  and 
the  thoracic  muscles ;  hence  inspiration  is  endangered  and 
cyanosis  may  result,  even  consciousness  being  lost  (Weiss). 
Trismus  is  rare,  yet  opisthotonos  is  not  exceptional.  Other 
muscles  may  be  affected,  as  of  the  eyes,  the  esophagus,  the 
pharynx,  the  larynx,  or  even  the  bladder.  Laryngeal  spasm  is 
a  common  accompaniment  of  the  disorder.  Naturally,  this 
degree  of  overtonicity  may  cause  muscular  pains.  The  degree 
of  spasm  varies,  and  also  its  length.  It  may  last  from  two 
minutes  to  two  hours  or  more.  As  has  been  said,  the  involve- 
ment of  the  muscles  is  symmetric.  Cases  have  been  reported 
of  one  side  only,  or  unilateral  for  a  time.  In  the  contracted 
muscles  fibrillary  twitchings  have  occurred  ;  clonic  movements 
almost  never.  Tremor  is  common.  The  spasm  begins  in  the 
periphery,  not  from  within  outward,  as  in  tetanus  ;  nor  are  the 
masseters  early  affected,  as  in  that  more  serious  malady  ;  nor  is 
reflex  excitability  high  ;  nor  is  the  spasm  continuous  as  in  tetanus. 
33 


514  DISEASES    OF    THE    NERVOUS    SYSTEM. 

During  the  intervals  the  patient  is  comparatively  comfortable. 
The  muscles  are  often  tender  and  sore,  and  they  are  weakened. 
The  intervals  are  variable  :  usually  a  few  hours,  or  it  may  be 
several  days  or  weeks.  Other  symptoms  are  those  of  Trousseau, 
already  mentioned.  This  is  the  phenomenon — that  if,  during  the 
passive  interval,  the  limb  be  grasped  in  such  a  way  that  the  great 
nerves  or  arteries  which  lie  along  the  under  surface  of  the  limbs 
are  pressed  upon  forcibly,  the  characteristic  cramp  can  be  made 
to  return.  It  may  require  some  continuance  of  this  pressure  to 
elicit  the  phenomenon,  but  when  it  is  present,  it  is  regarded  as' 
pathognomonic  of  tetany.  This  is  not  always  to  be  obtained : 
in  perhaps  only  one-fourth  of  all  cases.  Its  value  is  great  in 
demonstrating  the  existence  of  "latent  tetany,"  a  form  in 
which  there  is  at  no  time  a  clearly  marked  contracture.  Chvo- 
stek's  sign  is  rare  in  children.  It  consists  in  an  extraordinary 
susceptibility  of  the  nerves  in  tetany  to  mechanical  impressions. 
For  example,  a  blow  with  a  percussion  hammer  over  the  facial 
nerve  produces  a  twitching  of  the  angle  of  the  mouth  or  of  all 
the  muscles  of  the  facial  distribution. 

The  third  important  sign  of  tetany,  known  as  Erb's  sign,  is  a 
greatly  exaggerated  electric  excitability  of  the  nerves.  Weak 
faradic  or  galvanic  currents  produce  muscular  contractions  in 
excess  of  the  normal  response.  Cathodal  closure  contractions 
are  found  with  small  currents,  but  also  with  moderate  currents  ; 
also  cathodal  closure  tetanus  and  anodal  opening  tetanus,  which 
are  not  observed  in  any  other  condition. 

The  most  convenient  test,  and  one  which  usually  suffices  in  an 
affected  person,  is  the  increased  mechanical  excitability,  a  simple 
touch,  a  light  pressure  on  nerve,  being  enough  to  produce  con- 
tractions in  the  muscles  supplied  by  it.  It  is  less  painful  to  the 
subject  than  to  induce  an  attack  by  pressure  on  a  large  trunk  or 
artery  (B.  Sachs). 

Sensory  phenomena  are  few ;  there  are  no  disturbances  of 
cutaneous  sensibility.  Headache,  vertigo,  nystagmus,  and  tin- 
nitus aurium  are  described  as  coexisting.  Temperature  eleva- 
tion is  only  rarely  produced,  but  may  be  present  because  of 
some  underlying  condition. 

Respiration  is  not,  as  a  rule,  affected.  Dyspnea  is  sometimes 
produced  by  fixation  of  the  muscles  of  the  thorax  and  the 
diaphragm.  The  pulse  is  often  increased  in  frequency.  The 
urine  is  rarely  affected  ;  it  may  be  increased  in  amount.  Neph- 
ritis occurs  occasionally.  There  are  seen,  at  times,  certain  nutri- 
tive disturbances  affecting  the  hair,  nails,  etc.  The  reflexes  do 
not  show  any  characteristic  alterations,  and  are,  as  a  rule,  normal. 


TETANY.  5  I  5 

The  duration  of  an  attack  of  tetany  is  most  variable.  There 
may  be  many  remissions  of  greater  or  less  severity,  of  shorter 
or  longer  periods  of  abeyance. 

Diagnosis. — The  clinical  picture  of  tetany  is  thoroughly 
characteristic,  and  should  be  easily  recognized. 

The  position  of  the  hands,  the  fingers  grouped  together  or 
held  rigidly  in  this  or  some  other  attitude,  as  in  extension,  the  legs 
which  are  oftentimes  affected  as  well,  or  both  arms  and  legs  firmly 
adducted,  should  instantly  excite  suspicion.  On  investigation 
the  sign  of  Trousseau  would  reveal  the  condition,  even  during 
the  periods  of  latency ;  that  of  Chvostek  (irritability  to  slight 
mechanical  stimuli)  and  that  of  Erb  (electric  excitability,  as 
described)  should  make  the  diagnosis  clear.  Morse  regards 
the  one  symptom  pathognomonic  of  tetany  :  the  spontaneous 
intermittent  paroxysmal  contractions  of  the  muscles  of  the  fore- 
arms. 

Not  all  the  characteristic  symptoms  are  seen  in  each  case, 
and  the  absence  of  some  one  or  other  does  not  vitiate  the 
diagnosis. 

Pathologic  Anatomy. — No  constant  nor  characteristic  lesion 
has  been  found  present  at  autopsies  in  tetany.  Serous  exuda- 
tion into  the  cervical  cord  and  into  the  ventricles  of  the  brain, 
sclerotic  changes,  spinal  extradural  hemorrhage,  atrophy  in  the 
ganglion  cells  and  nerve-fibers,  and  proliferation  of  the  neuroglia 
are  among  the  conditions  found,  as  enumerated  by  Dercum. 

The  subject  has  been  variously  viewed  by  those  who  have 
made  researches  in  this  line  (Langhans,  Weiss,  Cowers,  Schles- 
inger,  and  others),  and  little  other  than  speculations  are  offered. 
The  facts  are  scanty  as  yet,  and  it  is  better  to  content  ourselves 
for  the  present  with  the  view  that  tetany  is  due  to  the  effects  of 
a  toxin  or  toxins  upon  the  entire  nervous  system  in  one  so  pre- 
disposed. 

Romme,  reviewing  the  claims  of  various  authors  as  to  the 
etiology  of  tetany,  concludes  that  the  views  of  Kassowitz  and 
his  school  (that  it  is  a  manifestation  of  rickets)  and  those  of 
others  who  would  ascribe  the  condition  to  any  especial  primary 
disease  are  incorrect,  as  there  are  no  constant  postmortem  find- 
ings in  tetany,  and  it  occurs  in  connection  with  various  dis- 
eases. 

Clinical  and  pathologic  studies  tell  us  only  that  the  main  symp- 
toms are  evidences  of  mechanical  or  reflex  hyperexcitability 
ol  the  cord  and  peripheral  nerves  due  to  a  diversity  of  causes. 

In  an  analytic  study  of  6822  children,  with  special  attention 
to  determining  the  nature  of  tetany  and  its  relationship  to  rickets 


516  DISEASES    OF    THE    NERVOUS    SYSTEM. 

and  laryngeal  spasm,  Cassel*  found  60  cases  of  tetany.  The 
nutrition  was  good  in  14,  moderately  good  in  13,  poor  in  23, 
and  bad  in  10.  All  presented  spontaneous  intermittent  spasm, 
which  could  be  induced  by  pressure  upon  the  large  nerves  and 
vessels  of  the  affected  parts.  In  all  but  3  the  facial  phenomenon 
was  present.  Only  2  had  laryngeal  spasm,  and  both  of  these 
presented  craniotabes  in  addition  to  other  symptoms  of  rickets. 
Without  exception  the  children  were  nervous  and  slept  badly. 
Fourteen  presented  a  rise  of  temperature  ;  in  9  the  disorder  was 
the  result  of  complicating  conditions  and  in  the  remainder  it 
arose  without  apparent  cause.  In  21  cases  digestive  disturbance 
preceded  or  accompanied  the  tetany  ;  in  5  there  was  chronic 
dyspepsia,  in  43  digestive  disorder,  in  6  obstinate  constipation, 
and  in  4  habitual  vomiting.  Rickets  was  present  in  52  of  the 
60  cases  ;  in  only  8  there  was  no  trace  of  rickets.  Tetany  was 
seen  throughout  the  entire  year,  although  the  largest  number 
appeared  to  occur  in  the  spring  and  late  autumn.  There  was 
no  suggestion  of  an  epidemic  occurrence  of  the  disease,  nor  was 
there  any  relation  as  to  frequency  between  tetany,  rickets, 
laryngeal  spasm,  and  craniotabes.  Cassel  concludes  that  tetany 
is  neither  a  complication  of  rickets  nor  of  digestive  disturbance, 
but  is  dependent  upon  unfavorable  conditions  of  living,  improper 
nutrition,  and  bad  air. 

The  evidences  point  to  the  conclusion  that  tetany  is  a  disorder 
of  the  nerves,  somewhat  generally  distributed,  and  of  toxic 
origin.  It  arises,  almost  always,  in  those  who  have  suffered 
from  exhausting  conditions,  depressing  circumstances,  or  acute 
diseases,  or  all  three. 

Prognosis. — The  prognosis  of  tetany,  on  the  whole,  is  favor- 
able. Most  cases  recover.  Sievers  notes  two  fatal  cases  which 
occurred  in  connection  with  dilatation  of  the  stomach.  In  both 
there  were  stenosis  of  the  pylorus  from  healed  ulcers  and  enor- 
mous dilatation. 

In  all  the  reports  of  fatal  cases  of  tetany,  twenty-seven  in  num- 
ber, there  was  usually  found  dilatation,  due  to  stenosis  from  scars 
of  pyloric  or  duodenal  ulcers,  or  ulcer  and  scar  without  stenosis. 
Those  cases  which  follow  upon  extirpation  of  the  thyroid  gland 
are  usually  fatal. 

Treatment. — If  rickets  be  accepted  as  the  essential  cause,  it 
is  plain  we  must  determine  what  has  produced  that  disease  ;  and 
the  findings  of  the  foremost  clinicians  yet  are  limited  here,  also,  to 
much  the  same  factors  as  give  origin  to  tetany.  The  disorder  is 

*"Deut.  med.  Woch.,"  Jan.  28,  1897. 


AUTOMATIC    MOVEMENTS. 


517 


one  chiefly  of  excess  of  motion  ;  and  prodigality  of  motion  —  as 
we  have  constantly  maintained,  in  dealing  with  disorders  of 
motion,  such  as  chorea  —  is  always  followed  by  exhaustion 
(fatigue  neurosis)  ;  hence  the  fundamental  need  for  all  such  states 
is  absolute  rest  for  both  body  and  mind.  The  next  indication  is 
to  remove  all  sources  of  peripheral  irritation.  The  mass  of  evi- 
dence is  in  favor  of  gastro-intestinal  irritation  being  the  chief 
factor  ;  hence  the  digestive  organs  will  need  fullest  attention.  As 
toxins  are  admitted  to  be  the  chief  source  of  disturbance  in  tet- 
any,  eliminants  are  also  in  order.  A  few  well-directed  doses  of 
calomel  will  meet  many  indications.  Beyond  this,  and  a  regula- 
tion of  diet,  it  is  seldom  needful  to  go.  If  the  spasmodic  phe- 
nomena are  excessive  or  painful,  it  is  well  to  proceed  in  the  same 
lines  as  in  dealing  with  convulsions.  The  inhalation  of  chloro- 
form, or  a  mixture  of  chloroform,  nitrite  of  amyl,  and  ether 
(parts  3,1,  and  5),  will  hold  the  spasm  in  check.  Sedatives,  such 
as  the  bromids,  chloral,  and  hyoscin  hydrobromate  may  then 
be  used,  or,  possibly,  morphin  hypodermically.  Finally,  nutri- 
tive tonics  will  be  required  in  most  cases,  and  to  be  maintained 
for  a  long  time.  (See  Convulsions.) 


AUTOMATIC   MOVEMENTS. 

Automatic  movements  may  occur  in  the  following  diseases  : 
(i)  Anomalous  epilepsy.  (2)  Hysteria  of  childhood,  exhibiting 
general,  quasipurposeful  movements  ;  also  hysteric,  salaam,  and 
hysteric  eclampsia  rotans.  (3)  Athetosis  (athetoid  movements 
in  asthenic  conditions).  (4)  Automatic  rhythmic  movements. 
These  are  better  displayed  in  a  table  : 

Movement   of  as- 


Automatic  rhythmic  movements 


Head  nodding  and  shaking, 


ments. 


«-, 

Head  banging. 

Eclampsia  nutans  or  salaam  convulsions. 

Eclampsia  rotans. 


(5)  Tic  convulsif.     (6)  Induced  automatic  movements. 

It  may  be  advantageous  to  examine  each  division  carefully  and 
endeavor  to  define  diagnostic  features  and  differences,  and  in  a 
few  instances  it  is  possible  to  assign  a  cause. 

Anomalous  Epilepsies.  —  In  this  form  there  is  exhibited  a 
most  marked  display  of  automatic  imperative  movements.  By 
relating  a  typical  case  a  good  concept  can  be  formed  :  A  boy, 
aged  seventeen,  weakly,  nervous,  and  irritable.  The  attack 


5l8  DISEASES    OF    THE    NERVOUS    SYSTEM. 

begins  usually  with  a  sharp  cry  and  without  further  development. 
The  patient  commences  to  run  aimlessly  through  the  street, 
usually  at  a  good  speed.  If  stopped  by  any  one,  he  may 
struggle  violently,  or  even  pass  into  epileptic  convulsions,  from 
which  he  awakens  exhausted,  asks  for  water,  and  promptly  goes 
to  sleep.  His  apparent  oblivion  to  the  external  world,  the  in- 
ability to  make  any  impression  by  speaking  to  him,  his  avoid- 
ance of  collision  with  objects  and  people,  and  particularly  his 
absence  of  remembrance,  when  he  awakes,  of  events  taking 
place  during  the  attack,  lead  one  to  regard  it  a  pure  case 
of  secondary  consciousness  of  automatic  and,  usually,  centric 
origin. 

Some  patients  run  round  and  round,  only  stopping  to  fall  ex- 
hausted and  senseless  to  the  floor.  Another  variety  manifests 
no  motor  excitation  whatever ;  the  patient  will  suddenly,  in  the 
midst  of  some  rational  action,  wander  quietly  off  by  himself, 
accost  persons  on  the  street,  and  at  times  threaten  to  do  violence 
if  the  one  addressed  does  not  agree  to  some  absurd  demand  on 
his  part.  Then  comes  the  awakening.  The  patient  does  not 
know  where  he  is  or  how  he  got  there,  and  exhibits  signs  of 
exhaustion  and  thirst. 

The  treatment  of  these  cases  is  the  same  as  that  for  idiopathic 
epilepsy. 

Hysteria  of  Childhood. — In  referring  here  to  hysteria,  we 
shall  simply  consider  that  type  in  which  there  are  observed 
automatic  movements. 

Hysteria  of  childhood  is  a  condition  which  frequently  simulates 
anomalous  epilepsy,  and  at  times  it  is  only  with  extreme  diffi- 
culty that  a  differentiation  can  be  made.  Like  epilepsy,  there  is 
often  an  initial  scream,  which  differs  in  quality  from  that  of  epi- 
lepsy, and  which  usually  is  not  given  until  the  patient  (usually  a 
female)  is  aware  that  she  has  an  audience.  The  patient  then 
falls  to  the  ground  in  a  way  that  she  may  not  be  hurt.  At  times 
a  very  fair  representation  of  opisthotonos  is  presented.  En- 
gorgement of  veins  about  the  head  is  frequently  noted,  and  more 
or  less  active  tonic  spasm  is  present.  After  this  follows  a  con- 
dition of  relaxation,  with  wild  quasipurposeful  movements  of  the 
arms  ;  broken  short  sentences,  explosions  of  passion  and  pro- 
fanity, weeping,  laughing,  and  grinding  of  the  teeth  follow.  The 
larger  and  more  sympathetic  the  audience,  the  more  varied  and 
emotional  will  be  the  manifestations. 

Anesthesia,  paralyses, hallucinations,  and  ecstasies  are  exhibited 
in  their  turn,  and  gradually  the  patient  quiets  down  to  normal. 
The  notable  feature  in  these  cases  is  the  imperative  and  purposeful 


AUTOMATIC    MOVEMENTS.  519 

movements,  mostly  confined  to  the  arms,  which  the  patient  will 
often  assert,  during  the  attacks,  she  can  not  possibly  stop. 

Athetosis  should  never  be  confused  with  any  other  automatic 
condition,  and  all  that  need  be  said  of  it  here  is  that  when  hys- 
teric, or  secondary  to  some  functional  or  mild  disorder,  good 
prognosis  may  be  given  ;  otherwise  it  should  be  guarded. 

Automatic  Rhythmic  Movements.  —  In  this  term  are 
broadly  included  head  nodding,  or  movements  of  assent  ;  head 
shaking,  or  negation  movements  (synonymous  with  spasmus 
nutans  and  nictitatio  spatia)  ;  gyrospasm  ;  head  banging  ;  eclamp- 
sia nutans,  or  salaam  convulsions  ;  and  eclampsia  rotans. 

Head  nodding  and  head  shaking  are  manifestations  which  ap- 
pear in  the  infant  at  any  time  between  the  ages  of  two  and  eighteen 
months.  They  are  sometimes  preceded  by  injury  to  the  head,  as 
might  be  occasioned  by  a  slight  fall.  But  the  condition  has  ap- 
peared so  many  times  when  such  history  can  not  be  elicited  that  it 
would  lead  one  to  think  an  injury  is  not  an  essential  factor  in  the 
etiology.  In  most  cases  the  nodding  and  shaking  are  preceded 
a  week  or  ten  days  by  nystagmus,  which  may  be  vertical  or  hori- 
zontal, or  vertical  in  one  eye  and  horizontal  in  the  other.  At 
times  there  is  only  a  uniocular  nystagmus.  When  the  nodding 
and  shaking  appear,  they  are  usually  limited  to  a  few  attacks  a 
day,  which  tend  to  increase  in  number.  There  sometimes  ap- 
pear cases  in  which  there  is  almost  constant  nutans  of  a  mild 
type,  with  strong  exacerbations.  In  the  great  majority  of  cases 
the  movements  seem  to  be  accentuated  when  the  attention  is  dis- 
tracted, or  if  the  child  makes  an  effort  to  hold  his  head  still. 
Caille  reports  cases  where  movements  ceased  when  attention 
was  fixed  and  also  if  eyes  were  bandaged.  His  treatment  of  the 
case  was  to  keep  the  eyes  bandaged  for  some  weeks — only 
removing  the  dressing  to  flush  out  the  conjunctiva.  Recovery 
ensued.  The  pupils  are  usually  dilated,  the  eye-grounds  normal. 
The  few  cases  in  which  fundus  changes  have  been  found  are  co- 
incidental. Occasionally  there  occur  periods  of  unconsciousness, 
with  marked  deviation  of  eyes  to  right  or  left  (Hadden). 

Very  frequently  there  is  a  history  of  rickets,  and  the  rosary 
and  other  features  are  well  marked.  In  most  of  Hadden's  cases 
there  occurred,  as  early  symptoms,  the  throwing  back  of  the 
head  and  looking  at  objects  with  partially  closed  eyes. 

Head  nodding  is  much  rarer  than  head  shaking.  Occasion- 
ally these  alternate  in  the  same  patient. 

If  it  be  desirable  at  this  time,  with  our  limited  knowledge  of 
the  condition,  to  classify  them  under  any  particular  heading,  hys- 
teria in  childhood  would  seem  to  present  the  greatest  claim,  for  in 


52O  DISEASES    OF    THE    NERVOUS    SYSTEM. 

hysteria  there  are  frequently  salaam  movements,  pure  and  simple. 
Until  more  is  known  of  the  essential  nature  of  those  conditions 
and  their  relation  to  the  few  different  lesions  which  have  been 
found  in  the  brain  at  death,  it  will  be  an  impossibility  for  us  to  go 
further  than  to  offer  surmises  as  regards  a  classification.  They 
are  so  frequently  associated  with  defective  mental  development 
that  the  suspicion  of  their  being  significant  of  some  deep-seated 
developmental  error  is  urgent. 

When  a  combination  of  motor  impulses  by  their  cross-action 
imparts  a  rotary  motion  to  the  head,  this  is  known  as  gyrospasm 
(Peterson).  These  spasmodic  conditions  sometimes  increase 
during  sleep.  According  to  Peterson,  the  number  of  excur- 
sions of  the  head  in  these  affections  rarely  exceeds  two  or  three 
a  second.  The  child  may  only  have  an  attack  during  the  night, 
or  it  may  be  so  persistent  that  it  suddenly  awakens  him  every 
time  he  composes  himself  for  sleep. 

The  following  is  a  case  of  gyrospasm  of  our  own  hitherto 
unreported :  B.  S.,  aged  six  months,  female,  Russian  Hebrew, 
of  excellent  family  history, — mother  a  large,  vigorous  woman 
with  abundant  breast  milk, — was  brought  to  Polyclinic  Dis- 
pensary for  relief  of  gyrospasm.  One  older  child,  perfectly 
strong,  was  also  breast  fed.  This  infant  was  regarded  as  excep- 
tionally vigorous,  had  never  been  ill,  held  up  its  head  at  three 
months,  and  had  no  convulsions.  Automatic  movements  began 
ten  days  ago  without  ascertainable  cause.  The  first  movement 
was  forward  and  back  nodding,  alternating  with  a  slight  rotary 
action,  noticed  from  time  to  time  during  the  morning  only.  On 
the  second  day  movement  was  more  marked  and  constant,  the 
series  consisting  of  two  or  three  nods,  followed  by  fifteen  or 
twenty  rapid  rotations,  then  a  quiet  interval.  In  all  there  were 
perhaps  twenty  paroxysms  during  the  day ;  these  are  now  con- 
tinuous, and  do  not  altogether  cease  during  sleep. 

On  examination  the  infant  seems  perfectly  normal  in  other 
respects  ;  is  cheerful  and  intelligent,  of  good  color,  and  well 
nourished.  On  endeavor  to  make  the  child  fix  its  eyes  or  con- 
verge them  the  movements  cease  for  a  few  seconds,  and  are 
replaced  by  lateral  nystagmus,  but  soon  the  gyrospasm  recurs 
with  increased  force.  Lowering  the  eyes,  the  head  leaning 
forward,  also  brings  relief.  The  case  recovered  entirely  in  a 
short  time. 

In  eclampsia  nutans  and  rotans  there  is  a  bowing,  or  salaam- 
ing, movement  of  the  neck.  Hadden  differentiates  those  condi- 
tions from  head  nodding  and  head  banging,  and  calls  eclampsia 
nutans  and  rotans  a  variety  of  epilepsy. 


EPILEPSY.  521 

In  anomalous  or  aberrant  forms  of  epilepsy  there  is  a  salaam- 
ing, but  also  there  are  other  signs  of  epilepsy. 

A  perfectly  analogous  condition  to  all  the  above  automatic 
imperative  movements  may  be  induced  by  suggestion  under 
hypnotism. 

Other  motor  neuroses — such  as  habit  chorea,  habit  spasm, 
convulsive  tics,  echolalia,  coprolalia — are  dealt  with  elsewhere. 

Treatment. — The  treatment  of  head  movements  is  change 
of  air  and  climate,  and  nutritious  food  and  out-of-door  life,  as 
much  as  possible  ;  in  short,  improved  hygiene,  careful  search 
being  made  for  and  correction  of  any  source  of  reflex  irritation, 
such  as  postnasal  adenoids,  adherent  prepuce,  phimosis,  denti- 
tional  disturbances,  intestinal  disorders,  intestinal  parasites,  etc. 

Most  of  the  sufferers  are  too  young  to  warrant  the  correction 
of  errors  of  refraction,  though  they  may  readily  exert  an  influ- 
ence. The  condition  of  any  of  the  aforesaid  irritations  may 
solve  the  difficulty.  It  is  safe,  nevertheless,  to  begin  at  once  on 
a  treatment  by  sedatives, — bromides,  valerian,  chloral,  etc., — 
nutritive  tonics,  such  as  cod-liver  oil,  iron,  phosphorus  ;  fatty 
and  albuminous  foods,  and  the  organic  nucleo-albumins  are 
likewise  indicated.  H.  C.  Wood  likens  these  conditions  to 
those  of  chorea,  which  is  due,  in  his  opinion,  to  depression  of 
the  inhibitory  centers  governing  the  anterior  cornual  cells  of  the 
cord.  He  accordingly  recommends  quinin  as  an  inhibitory 
stimulant. 


EPILEPSY. 

Epilepsy — the  falling  sickness,  morbus  sacer  of  the  ancients — 
is  a  syndrome  or  a  collection  of  symptoms  rather  than  a  dis- 
ease. It  is  one  of  the  hereditary  diseases  or  disorders  of  the 
nervous  system,  characterized  by  paroxysms  of  unconsciousness, 
associated  with  or  occasionally  without  convulsions. 

The  causes  of  epileptic  seizures  are  of  infinite  variety.  In  the 
majority  of  cases  epilepsy  begins  before  puberty,  and  rarely  after 
the  twenty -fifth  year.  Heredity  plays  an  important  role  :  35  per 
cent,  of  Gowers'  cases  were  due  to  heredity.  Families  in  whom 
neuralgia,  hysteria,  insanity,  or  any  other  neurosis  prevails  are 
most  liable  to  fall  victims  to  this  malady.  Any  cause  which 
impairs  the  general  health  and  exhausts  the  nervous  system  acts 
as  a  predisposing  influence.  Chronic  alcoholism,  syphilitic  taints 
(in  parents),  trauma  existing  from  childhood,  infectious  dis- 
eases of  childhood,  reflex  irritations,  intestinal  worms,  disordered 
dentition,  adherent  prepuce,  foreign  body  in  nose  or  ear,  and 


522  DISEASES    OF    THE    NERVOUS    SYSTEM. 

errors  in  ocular  refraction  have  been  claimed  by  eminent  clini- 
cians as  predisposing  factors. 

Epileptoid  disorders  are  now  becoming  more  carefully  dif- 
ferentiated and  grouped  into  such  classes  as  can  be  shown  to 
have  a  common  cause :  for  example,  hysteria,  which  imitates 
so  closely  many  diseases,  puerperal  convulsions  or  eclampsia, 
uremic  convulsions  and  other  toxemias,  the  common  convulsive 
prodromes  of  the  infectious  diseases,  and  certain  degenerative 
processes. 

The  name  epilepsy  is  given  to  a  large  group  of  convulsive 
disorders,  the  causes  of  which  are  unknown,  though  they  may 
be  shrewdly  suspected  by  reason  of  facts  which  are  progressively 
less  easy  to  interpret.  When  a  local  area  of  the  brain  cortex  is 
disordered  sufficiently  to  produce  irregular  discharges,  it  is 
called  "focal  epilepsy."  These  cases  maybe  explained  by  a 
focus  of  inflammation,  a  new  growth,  or  an  injury  to  the  skull. 

In  a  smaller  group  of  epilepsies  the  cause  can  not  be  differen- 
tiated, and  these  are  still  misdescribed  by  the  term  idiopathic. 
It  is  generally  admitted  (certainly  this  is  our  conviction)  that  a 
predisposition  to  convulsive  states  is  required  for  most  causes  to 
act  upon,  and  this  is  especially  true  for  reflex  causes! 

Instability  of  nervous  equilibrium  will  render  one  child  vulner- 
able to  slight  motor  influences,  whereas  another,  similarly  or 
even  worse  exposed,  may  escape  convulsions. 

Causes. — The  causes  of  epilepsy  are  various.  Focal  epilepsy 
is  recognized  to  be  due  to  a  demonstrable  lesion,  injury,  or  new 
growth.  The  idiopathic  forms  are  explainable  upon  some  con- 
ditions of  degeneration,  the  results  of  hereditary  or  congenital 
states,  and  not  capable  of  graphic  postmortem  demonstration. 

Alcoholism  in  the  parents  is  potent  to  induce  the  degenerative 
processes,  or  further  to  impair  nervous  stability  and  increase  an 
existing  susceptibility.  It  is  our  conviction  that  when  all  things 
are  considered,  alcohol  is  an  agent  responsible  for  a  much  larger 
number  of  instances  of  degeneration  than  any  other  single  agent. 

Morbid  Anatomy. — Gross  deformities,  such  as  absence  of  a 
part  of  the  brain  (porencephalia)  or  areas  of  changed  consistency 
(sclerosis,  softening,  or  the  like),  are  to  be  classed  under  proper 
heads.  These  contribute  to  the  production  of  mental  impairment 
or  destruction.  In  chronic  epilepsies  there  have  been  found  areas 
of  sclerosis, — especially  in  the  horn  of  Ammon  (Fere), — neu- 
rogliar  sclerosis  (Chaslin),  a  real  gliosis  or  proliferation  of  the 
neuroglia. 

Symptoms. — The  one  most  conspicuous  factor  in  epilepsy  is 
the  convulsion,  an  explosion  of  nervous  discharge  from  the  brain 


EPILEPSY.  523 

centers.  The  convulsion  is  apparently  dependent  upon  cellular 
instability  of  the  motor  centers.  Trivial  irritation  of  these  cen- 
ters causes  the  epileptic  fits.  This  is  accompanied  by  a  loss  of 
consciousness  and  various  physical  disorders.  The  more  impor- 
tant feature  by  far  is  the  psychic  disturbances. 

The  most  graphic  feature  of  epilepsy  is  the  fit.  This  is  com- 
monly subdivided  into  two  distinct  varieties — major  attacks,  or 
grand  mat,  and  minor  attacks,  or  petit  mat.  It  is  only  too  com- 
mon to  find  those  who  suffer  from  both  varieties.  While  there 
is,  even  in  the  same  individual,  a  sliding  scale  between  these  two 
varieties,  yet  there  are  very  distinct  differences,  especially  in  the 
line  of  prognosis,  the  lesser  attacks  being  much  more  difficult  to 
control.  During  the  interval  there  is  little  or  nothing  to  distin- 
guish the  sufferer  from  a  well  person.  The  disorder  consists  of 
an  ever-present  tendency  for  the  victim  to  suffer  from  a  fit  or 
convulsion,  briefer  protracted,  accompanied  by  psychoses  of  the 
gravest  importance.  In  most  cases — and  they  are  the  fortunate 
ones — there  is  a  distinct  warning,  more  or  less  definite  and  ex- 
tensive. Those  who  possess  this  are  enabled  to  seek  a  place  of 
safety  before  the  attack  overmasters  them  ;  they  are  also  enabled 
to  use  remedies  which  are  sometimes  successful  in  warding  off 
the  worst.  These  prodromes  are  sometimes  vague  sensations 
referred  to  the  stomach,  or  curious  sensations,  as  formication  in 
the  extremities.  At  times  these  consist  of  slight  twitching  move- 
ments or  mental  or  emotional  states,  restlessness,  irritability  of 
temper,  or  excitement.  Sometimes  the  vision  is  affected  or  other 
sensory  aurae  exist.  The  chief  symptoms  of  an  attack  of  major 
epilepsy  are  thus  arranged  by  Sachs,  in  their  order  of  importance 
and  their  usual  occurrence  : 

1.  Prodromes,  generally  of  a  sensory  character.     At  times 
there  is  a  vasomotor  or  psychic  disturbance. 

2.  Initial  cry. 

3.  Loss  of  consciousness  (very  sudden). 

4.  Pupils  dilated  ;  no  reaction. 

5.  Tonic  or  clonic  spasm  of  muscles  (unilateral,  partial,  or 
general).    . 

6.  Spasm  of  respiratory  muscles,  which  may  lead  to  asphyxia. 

7.  Spasm  of  the  muscles  of  the  jaw  (biting  of  the  tongue, 
bloody  foam). 

8.  Spasm  relaxes  and  movements  become  clonic  and  then  in- 
termittent. 

9.  Involuntary  passage  of  urine  or  of  feces. 

10.  Gradual  recovery  of  consciousness,  followed  by  a  pro- 
longed stupor  or  profound  sleep. 


524  DISEASES    OF    THE    NERVOUS    SYSTEM. 

In  a  disorder  which  offers  so  many  possibilities  for  accidental 
extraneous  damage  it  is  most  valuable  for  the  sufferer  to  obtain 
adequate  warning.  In  a  reasonable  proportion  of  cases  this  is 
furnished,  usually  by  certain  sensory  phenomena,  or  it  may  be 
slight  movements  ;  others  may  evidence  excitement,  irritability, 
or  aphasia  ;  the  kind  of  aura  may  act  as  a  key  to  the  form  of 
seizure,  or  point  to  the  cause.  When  the  aura  is  clear  and 
rightly  interpreted  by  the  patient,  an  invaluable  opportunity  is 
afforded  to  seek  a  place  of  safety  or  otherwise  prepare  for  the 
oncoming  period  of  unconsciousness. 

Partial  or  unilateral  epilepsy  points  toward  foci  of  organic 
mischief.  In  this  form  of  epilepsy,  spoken  of  as  Jacksonian,  there 
is  usually  undisturbed  consciousness.  General  convulsions 
rather  indicate  hereditary  or  idiopathic  forms.  The  localized  con- 
vulsions may  at  any  time  become  general,  and  then  there  is  prac- 
tically no  ground  for  differentiation.  It  is  wise  to  search  care- 
fully into  the  history  of  every  case  for  hereditary  or  parental 
causes,  and  into  the  personal  history  of  possible  trauma  during 
birth,  and  the  exact  form  of  attack  as  indicating  possible  organic 
brain  trouble.  All  this  will  potently  influence  both  prognosis 
and  treatment.  . 

In  a  certain  number  of  instances  the  attack  is  almost  altogether 
motor  and  occurs  during  sleep.  This  is  called  by  Lloyd  "  som- 
naic  epilepsy,"  a  better  term  than  "  nocturnal,"  as  it  is  during 
sleep  the  attack  occurs  be  this  by  day  or  night. 

Masked  epilepsy  is  that  variety  in  which  the  sensory  and 
motor  features  are  replaced  by  psychoses,  often  mere  vagaries, 
but  sometimes  maniacal  outbreaks.  These  cases  are  often  most 
obscure  and  require  close  study  and  emphatic  warning  to  parents 
and  caretakers. 

By  far  the  most  important  symptoms  of  epilepsy  are  the 
psychic  phenomena.  "  Epilepsy  is  much  more  than  a  fit :  its 
essential  factor  is  a  wide-spread,  degenerative  process  which  in- 
volves not  only  the  sensory  and  motor  cortex,  but  also  the  high- 
est intellectual  centers  of  the  brain  "  (Lloyd). 

In  certain  cases  disordered  mental  states  accompany  the  aura : 
confusion,  fear,  or  anger  arises,  which  passes  into  the  convulsion 
or  stupor. 

Episodes  of  maniacal  fury  may  replace  the  ordinary  features  of 
the  paroxysm,  or  pass  into  other  forms  of  mental  derangement, 
as  of  confusional  states,  delusions,  or  moral  perversions.  Masked 
epilepsy  or  moral  mania  may  follow  the  paroxysm,  hence  we 
have  preepileptic  and  postepileptic  states  of  a  most  important  and 
dangerous  character,  and  belonging  as  an  essential  factor  to  it. 


EPILEPSY.  525 

Many  of  the  large  viscera  are  affected,  impairing  function  and 
jeopardizing  life.  Digestion  is  frequently  disordered,  especially 
after  the  fit,  as  well  as  loss  of  control  over  sphincters  and  tran- 
sient albuminuria.  Gastro-intestinal  disorders  also  precipitate 
the  fit,  and  the  removal  of  these  changes  both  the  severity  and 
character  of  the  disease. 

When  the  disorder  has  begun  in  early  life,  various  stigmata 
of  degeneration  are  often  seen,  such  as  asymmetries  of  cra- 
nium and  face,  stunted  growth,  poor  teeth,  and  low-type  ears  and 
genitalia. 

Diagnosis. — In  epilepsy  the  aura,  suddenness  of  the  attack, 
and  loss  of  consciousness,  accompanied  by  tonic  and  clonic 
spasms,  are  distinctive  features.  If  these  are  repeated  at  more  or 
less  regular  intervals,  the  diagnosis  is  conclusive.  Exaggerated 
deep  reflexes  in  one  half  of  the  body  indicate  a  preceding  hemi- 
plegia  as  the  cause. 

Hysteria  simulates  epilepsy,  but  there  are  obvious  points  of 
difference  in  the  history,  degree  of  unconsciousness,  etc.  Ure- 
mia induces  fits  very  like  the  disorder,  but  is  to  be  recognized 
by  the  history  and  urinalysis.  Organic  brain-lesions  induce 
convulsions  closely  resembling  epilepsy.  In  these  cases  are  also 
paralyses  of  motion  and  sensation,  optic  neuritis,  vomiting,  acute 
mental  symptoms,  headaches,  and  the  special  history. 

Reflex  epilepsy  in  children  from  gastro-intestinal  disorders  oc- 
curs in  those  who  are  strongly  predisposed  to  convulsive  states 
or  already  damaged  by  infectious  diseases. 

Possibly  a  cure  can  be  effected  here  before  the  condition  pro- 
gresses too  far. 

Prognosis. — A  cure  is  possible  in  a  few  favorable  cases  not 
dependent  on  gross  brain  changes.  In  chronic  cases,  from  what- 
ever cause,  little  hope  can  be  held  out,  although  no  effort  must 
be  spared  to  strive  to  control  the  convulsions,  which  in  their 
progress  work  mischief,  and  it  is  always  possible  that  a  good 
result  may  be  achieved. 

Surgery  affords  increasing  possibilities  year  by  year.  We  have 
seen  one  case  get  entirely  well,  although  morbid  impulses  re- 
mained. The  outlook  is,  however,  far  from  brilliant. 

Treatment. — The  treatment  of  epilepsy  should  always  em- 
brace two  considerations  :  One  directed  to  the  prevention  of  the 
attack,  and  the  other  to  the  control  of  the  nervous  discharges 
or  overaction  of  the  cortical  cells.  As  has  been  shown,  grave 
instability  of  the  nervous  cells  in  an  individual  renders  him  ex- 
tremely susceptible  to  potent  irritants  of  all  sorts,  psychic  and 
physical.  Every  means  should  be  employed  to  maintain  the 


526  DISEASES    OF    THE    NERVOUS    SYSTEM. 

patient  on  an  even  plane,  in  a  wholesome  equilibrium.  All  cir- 
cumstances calculated  to  produce  gross  disturbances  should  be 
avoided.  Overcrowding,  close  atmosphere,  extreme  excitement, 
digestive  disturbances,  are  in  themselves  capable  of  precipitating 
an  attack.  A  sufferer  from  epilepsy  should  live  a  life  of  great 
regularity,  provided  with  suitable  amusement,  occupation,  and 
education,  and  be  kept  as  much  as  possible  in  the  open  air. 
The  organs  of  digestion  should  receive  especial  and  unremitting 
care.  A  single  indiscretion  may  bring  on  a  fit,  neglect  of 
bowel  evacuation,  and,  above  all,  if  intestinal  putrefaction  takes 
place,  this  may  not  only  induce  an  attack,  but  actually  be  the 
starting-point  of  the  disease  in  one  so  predisposed.  The  skin 
should  receive  adequate  attention  and  cool  bathing  ;  sea-baths 
and  sometimes  hot  or  medicated  baths  and  oil  inunctions  are 
valuable  auxiliary  measures.  Sleep  should  be  undisturbed  and 
sound.  Tranquilizing  medicines  had  better  be  given  increasingly 
toward  night.  Above  all,  there  should  be  secured  moral  and 
mental  tranquillity  and  contentment.  By  such  means  as  these 
alone  the  seizures  may  be  markedly  lessened  in  severity  and 
oftentimes  in  numbers.  Many  reflex  sources  of  irritation  have 
been  accredited  with  the  power  of  producing  the  disease,  such  as 
eye-strain,  disordered  ocular  muscle  balance,  refractive  errors,  and 
the  like,  adenoid  growths,  laryngeal  irritation,  adherent  prepuces, 
intestinal  parasites.  Indeed,  the  whole  train  of  reflex  irritations 
are  more  or  less  efficient  as  well  as  instrumental  causes,  which 
should  always  be  removed  or  sedulously  controlled. 

Of  drugs,  the  bromids  have  held  first  place  in  spite  of  all 
rivals.  They  are  not  curative,  strictly  speaking,  but  through 
their  use  some  cases  have  recovered.  At  least,  the  use  of 
bromids,  especially  if  judiciously  administered,  with  proper  reg- 
ulation and  safeguards,  mitigate  most  admirably  the  severity  and 
number  of  the  attacks,  not  seldom  keeping  them  off  successfully, 
and  enabling  the  patient  to  be  a  useful  citizen.  The  action  of 
the  bromids  is  generally  held  to  be  chiefly  that  of  motor  depres- 
sants, checking  the  overexcitability  of  the  cortical  cells.  There 
is  evidence  to  show  that  they  exert  another  quality  by  lessening 
the  activity  of  the  toxins  circulating  in  the  blood,  which  at  or 
near  a  convulsive  seizure  are  distinctly  more  virulent.  Of  the 
form  of  bromid,  the  salt  of  potassium  is  most  widely  used,  but 
that  of  sodium  is  even  better,  and  of  lithium  better  still  ;  ammo- 
nium bromid  may  be  used  ;  a  mixture  of  several  bromids  is 
claimed  to  be  of  exceptional  value,  and  it  is  usually  best  to  use 
them  in  combination.  Much  has  been  claimed  for  the  bromid 
of  strontium,  which  exerts  far  less  disturbance  on  the  stomach, 


EPILEPSY.  527 

skin,  and  mentality,  and  is  the  best  for  children.  The  best 
menstruum  for  the  bromids  is  an  essence  or  elixir  of  pepsin.  It 
is  also  well  to  give,  along  with  these,  both  arsenic  and  iron,  not 
only  for  their  action  in  overcoming  the  depreciating  effects  of  the 
bromids  upon  the  blood,  but  for  their  own  tonic  properties. 
The  doses  of  the  bromids  should  be  adjusted  to  secure  a  definite 
effect,  increasing  or  lessening  them  as  they  exert  a  recognizable 
influence  over  the  fit.  There  is  also  another  rule  useful  to 
remember,  and  that  is  to  give  the  doses  increasingly  toward 
night,  with  the  largest  dose  at  bedtime,  both  because  the  patient 
is  better  for  thoroughly  sound  sleep  and  also  to  mitigate  the 
disagreeable  effects  which  the  drug  may  exert  throughout  the 
waking  hours.  Children  bear  the  bromids  well.  Other  drugs  are 
useful  for  their  tranquilizing  properties,  and  are  often  added  with 
value  to  the  bromids — namely,  antipyrin,  iodid  of  potassium,  bel- 
ladonna, especially,  and  also  chloral  hydrate,  acetanilid,  and  a 
host  of  others.  Along  with  a  bromid  powdered  charcoal  in 
essence  of  pepsin  or  pancreatin  is  useful  when  accompanied  by 
fermentative  dyspepsias.  To  replace  the  bromids  for  a  shorter 
or  longer  period  sulphonal  serves  a  good  purpose,  and  trional 
also,  and  occasionally  the  opiates  or  codein  with  great  caution. 
Changes  in  drugs  must  frequently  be  made,  and  most  cases 
improve  surprisingly  with  every  change  for  a  time.  Flechsig 
has  emphasized  the  value  of  a  bromo-opiate  combination,  using 
the  opiate  in  the  solid  form  in  increasing  doses  for  six  weeks  ; 
then  abruptly  replacing  this  by  bromids.  Cases  of  long-stand- 
ing epilepsy  not  otherwise  relieved  are  thus  sometimes  much 
benefited. 

Drugs  which  have  the  effect  of  lessening  connective  tissue  or 
neurogliar  proliferation  exert  a  peculiar  influence,  among  which 
are  the  iodids,  various  preparations  of  mercury  and  arsenic, 
nitrate  of  silver,  and  zinc. 

Certain  remedies  deserve  mention  in  connection  with  special 
forms  of  epilepsy.  Inhalations  of  amyl  nitrite,  suggested  by 
Weir  Mitchell,  are  of  greatest  utility  where  there  is  an  aura, 
recognizable  by  the  patient  in  time  to  make  use  of  it.  This  is 
well  combined  with  chloroform,  and  is  especially  useful  in  the 
status  epilepticus. 

When  the  heart  is  at  fault,  lacking  tone  or  rhythm,  etc., 
cardiac  tonics,  such  as  digitalis,  are  of  value  alone  or  along  with 
other  drugs.  If  the  vascular  tension  is  too  high,  this  is 
relieved  by  the  nitrites.  Belladonna  is  a  useful  adjuvant  too — 
hyoscin  hydrobromate  or  coniin  hydrobromate  when  a  change 
in  the  form  of  motor  depression  is  needed.  Almost  any  new 


528  DISEASES    OF    THE    NERVOUS    SYSTEM. 

plan  of  treatment  is  followed  by  improvement  for  a  time.  The 
best  results  are  had  from  healthy,  tranquil  outdoor  life,  with 
limited  dietary  and  rigid  attention  to  the  emunctories. 

CHOREA. 

Synonyms. — SYDENHAM'S  CHOREA;  CHOREA  MINOR;  ST.  VITUS' 

DANCE. 

Chorea  is  a  functional  nervous  disease  of  childhood  and  early 
adolescence,  characterized  by  sudden,  rapid,  irregular,  and  invol- 
untary twitching  of  some  or  all  of  the  muscles  of  the  body,  and 
by  a  deficient  control  of  the  muscles  affected. 

The  movements  produced  are  unexpected  and  can  not  be 
accurately  imitated  nor  voluntarily  checked  for  any  length  of 
time.  Attention  or  excitement  may  increase  them  ;  so,  indeed, 
does  the  effort  to  restrain.  This  difference  may  mark  the  type 
or  alternate  more  or  less. 

In  milder  forms  the  twitchings  are  brief,  but  in  a  few  instances 
the  movements  are  so  large  and  violent  as  to  imperil  life  or  limb, 
and  by  the  constancy  of  passive  muscular  acts  tend  to  exhaust 
the  sufferer  most  profoundly.  This  exhaustion  must  not  be 
overlooked  in  treatment  and  plays  a  part  in  all  cases. 

Two  classes  of  movements  are  recognized  :  In  the  one  these 
lessen  notably  on  voluntary  movement  in  coordinate  acts  (passive 
chorea),  and  in  the  other  they  greatly  increase,  often  rendering 
the  result  of  attempted  effort  impossible  (intention  chorea).  The 
disorder  is  more  apparent  in  the  extremities,  most  commonly  in 
the  hands  and  muscles  of  the  face  and  tongue,  producing 
grimaces,  especially  while  talking.  The  lower  limbs  are  also 
much  disturbed,  rendering  locomotion  peculiar,  producing  a 
characteristic  awkwardness,  and  oftentimes  an  uneasy  fidgeting 
about  the  body  and  shoulders.  One  of  the  commonest  forms  is 
for  the  arms  to  jerk  suddenly  back  while  making  an  effort  to 
reach  for  an  object,  and  in  another  the  face  muscles  are  distorted, 
causing  a  most  imbecile  appearance,  with  which  chagrin  at 
failure  to  maintain  control  has  much  to  do. 

The  endeavor  to  stand  still  controls  the  movements  for  a 
few  seconds,  to  be  followed  by  greater  intensity  of  the  dis- 
ordered action.  Chorea  may  be  of  one  side  only  (hemichorea), 
in  about  one-third  of  cases  (Starr),  and  recurrences  are  liable  to 
arise  in  the  same  limited  way.  In  two-thirds  of  cases  the 
ataxia  affects  both  sides,  or  in  a  few  instances  it  is  bilateral,  but 
greater  on  one  than  on  the  other  side. 

In  rarer  cases  there  is  but  slight  movement  and  marked  muscle 


CHOREA.  529 

paresis.  Speech  is  often  disordered  (dysarthria),  due  to  choreic 
action  of  the  muscles  used  in  articulation  and  also  in  respiration. 
The  rare  instances  of  laryngeal  chorea  cause  sounds  to  be  emitted 
like  the  yelping  of  a  dog,  but  these  should  not  be  confounded 
with  hysteric  barking. 

The  mental  disturbances  described  by  some  writers  as  occurring 
in  chorea  are  much  more  likely  to  be  due,  as  Sachs  points  out,  to 
exhaustion  ;  and  the  irregularity  of  temper  is  a  natural  sequence 
of  the  long  and  exasperating  agitation  of  both  body  and  mind. 

A  frequent  complication  of  chorea  is  rheumatism,  by  many 
ascribed  as  a  cause  in  about  one-fourth  of  cases  ;  the  most  serious 
complication  is  disease  of  the  heart,  which  may  be  and  usually  is 
due  to  the  same  factor.  Rheumatism  in  a  child  is  not  readily 
recognized  by  temperature  and  swellings,  but  must  be  searched 
for  among  the  more  obscure  symptoms,  as  fleeting  pains  ("  grow- 
ing pains  ")  and  joints  becoming  tender  upon  pressure. 

Causes. — Chorea  is  a  neurosis  of  childhood  and  youth,  occur- 
ring from  birth  to  late  old  age,  but  oftenest  at  or  about  the 
thirteenth  year,  the  majority  of  cases  between  five  and  fifteen. 
Hereditary  predisposition  is  a  marked  factor,  as  well  as  descent 
from  choreic  parents  and  also  those  who  are  sufferers  from  epi- 
lepsy and  migraine  and  other  neuroses. 

Females  are  three  times  more  subject  to  chorea  than  males. 
Season  exerts  a  marked  influence,  by  far  the  largest  number 
arising  in  the  spring  (May  to  July  ;  next,  December  to  February, 
according  to  Morris  Lewis,  Weir  Mitchell,  and  Starr),  but  Put- 
nam and  Gowers  do  not  confirm  this  view. 

Anemia  and  the  bad  hygiene  which  causes  it  are  at  the  founda- 
tion of  many  cases,  and  are  commonly  found  associated  with  the 
disorder. 

The  direct  causes  of  St.  Vitus'  dance  are  fright,  overwork, 
such  as  study,  rheumatism,  and  the  acute  infectious  diseases. 
Fright  is  the  most  powerful  for  harm,  and  many  instances  are 
recorded  in  which  this  seems  the  only  accountable  reason.  In  at 
least  one-third  of  the  cases  it  has  been  shown  to  be  the  exciting 
cause.  Various  peripheral  reflex  causes  are  pointed  out  as 
etiologic  factors,  especially  gastro- intestinal  disturbances,  ocular 
defects,  nasopharyngeal  growths,  etc. 

There  is  a  similarity  in  the  causal  factors  of  both  chorea  and 
rheumatism,  and  these  may  produce  the  one  or  the  other. 
Neurotic  heredity  is  an  important  factor.  Heart  disease  also 
often  precedes  the  neurosis.  We  have  had  well-marked  cases 
of  endocarditis  in  which  chorea  subsequently  developed  during 
or  late  in  the  attack. 
34 


53O  DISEASES    OF    THE    NERVOUS    SYSTEM. 

The  relation  of  chorea  and  epilepsy  is  most  interesting  and 
warrants  further  study. 

Symptoms. — Chorea  comes  on  gradually,  as  a  rule,  by  slight 
irregularities  of  purposeless  movement  and  increasing  steadily  or 
suddenly.  The  child  drops  objects  and  is  considered  awkward, 
may  trip  and  stumble,  and  make  strange  faces.  Fully  developed 
chorea  is  unmistakable  and  obvious.  Movements  usually  cease 
in  sleep. 

The  heart  in  all  cases  should  be  repeatedly  and  most  care- 
fully watched.  Mitral  regurgitant  murmurs  are  commonest. 
Aortic  disease  is  rare.  True,  these  do  sometimes  entirely  pass 
away,  and  it  is  impossible  to  be  sure  of  organic  disease  existing 
or  persisting,  especially  as  anemia  is  a  frequent  accompaniment 
of  the  disorder  as  well  as  a  slight  dilatation  of  the  heart.  It  is 
possible  that  some  of  these  murmurs  may  be  due  to  chorea  of  the 
heart  muscles.  The  urine  is  frequently  loaded  with  uric  acid — 
an  indication  of  profound  disturbance  of  nutrition.  Subcutane- 
ous nodules,  occasionally  seen,  have  a  probable  origin  in  rheu- 
matic states. 

The  whole  clinical  picture  in  chorea  is  of  an  irritable,  miser- 
able child,  not  ill,  but  wretched  and  enfeebled,  of  poor  appetite 
and  sleep,  exhausted,  often  apathetic,  and  at  times  suffering  pain 
from  headaches,  etc.  The  average  duration  of  chorea  is  put  at 
about  ten  weeks,  and  recurrences  are  frequent  at  short  or  long 
intervals — often  two  or  three,  and  as  many  as  eight,  times 
(Sachs).  Weir  Mitchell  teaches  that  during  spring  and  fall  these 
sufferers  should  be  kept  under  observation  for  preventive  treat- 
ment before  the  usual  times  for  recurrence. 

The  relapses  vary  greatly,  from  a  few  weeks  to  as  many 
years,  usually  of  medium  type,  but  not  always.  They  may 
recur  in  similar  form,  but  often  presenting  quite  a  different 
character  of  movements. 

In  certain  recent  studies  of  choreiform  movements  by  Weir 
Mitchell  and  J.  H.  W.  Rhein  the  conclusions  are  as  follows  : 

1.  There  are   cases  which   show,  some  at  one   stage,   some 
throughout   their    course,   absence    of  movement    during    rest. 
The   movements,   mild   or  severe,   are    developed    only   during 
muscular  acts. 

2.  Others  in  whom  continued  movement  is  greatly  increased 
during  intentional  effort. 

3.  In   certain   cases  the   movement  disappears  during  inten- 
tional muscular  acts. 

4.  Others  again  appear  unaltered  by  voluntary  muscular  acts. 

5.  In  a  few  cases  the  various  types  alternate  or  shift. 


THE 


CHOREA.  531 

A  tremor  exists  in  some  cases  of  chorea,  replacing  in  part  the 
ordinary  movements,  or  this  may  coexist  with  them. 

In  some  few  cases  the  movement  is  rhythmic  and  vibratory, 
resembling  a  large  tremor. 

The  diagnosis  is  usually  easy  enough.  The  character  of  the 
movements  is  so  clearly  marked  as  to  serve  all  through  medical 
phraseology  as  a  descriptive  term,  such  as  "  choreic  "  or  "  chorei- 
form."  Sachs  calls  attention  to  the  "  facies "  of  chorea,  of 
which  the  chief  point  is  the  peculiar  attitude  of  the  protruded 
tongue. 

Weir  Mitchell  long  ago  called  attention  to  a  variety  of  inco- 
ordinate movements  following  cerebral  paresis  or  descending 
atrophies,  to  which  he  gave  the  name  of  "  postparalytic  chorea." 

Writers  have  variously  discussed  this  pro  and  con.,  but  some 
of  the  best  observers  admit  that  the  resemblance  of  these  mobile 
spasms  to  true  chorea  is  so  close  that  differential  diagnosis,  aside 
from  a  history  of  cerebral  origin,  is  almost  impossible.  The 
points  for  contrast  are  the  reflexes  (increased  in  cerebral  trouble), 
contractures,  rigidity,  etc.,  not  found  in  uncomplicated  functional 
chorea.  When  chorea  is  persistent,  it  is  often  possible  to  find 
evidences  of  cerebral  lesion.  This  form  of  chorea  is  not  so 
common  (6  per  cent,  of  cases)  as  athetosis  in  the  cerebral  con- 
ditions. 

Pathology. — No  end  of  structural  lesions  of  the  brain  have 
been  accused  of  giving  origin  to  chorea,  but  the  discrepancy  of 
these  various  opinions  is  so  marked  that  their  value  is  nil.  Most 
of  the  changes .  described  are  secondary  to  various  precedent  con- 
ditions, and  in  the  younger  cases,  as  a  rule,  but  also  in  children 
old  enough  to  have  had  various  lesions. 

The  changes  observed  are  mostly  cortical,  and  there  is  usually 
some  change  in  the  gray  matter  of  the  central  nervous  system. 
The  tendency  is  to  regard  chorea  as  due  to  primary  vascular 
changes  which  maybe  dependent  upon  infectious  processes.  The 
true  pathology  of  chorea  is  unknown  as  yet.  Barbour  maintains 
that  in  chorea  there  is  an  altered  state  of  nutrition  of  the  motor 
cells  of  the  cerebrospinal  axis,  by  reason  of  which  they  lose  in 
part  their  capacity  for  storing  nerve  force,  and  discharge  them- 
selves prematurely  :  Money  encountered  capillary  emboli  in  the 
optic  thalamus  ;  Flechsig  found  hyaline  changes  in  the  two  ante- 
rior divisions  of  the  lenticular  nucleus  ;  Dana  found  an  intense 
cerebral  and  spinal  hyperemia,  dilatation  of  the  vessels,  small 
hemorrhages,  spots  of  softening,  and  an  infiltration  of  the  perivas- 
cular  spaces  with  round  cells  ;  Carrod  suggests  the  possibility 
that  chorea  is  due  to  an  overgrowth  of  connective  tissue  in  the 


532  DISEASES    OF    THE    NERVOUS    SYSTEM. 

nerve  centers  ;  Golgi  found  calcification  of  the  Purkinje  cells  of 
the  cerebellum  ;  and  Elischer  saw  hyaline  degeneration  in  the 
nerve-cells  of  the  central  ganglia.  We  can  not  say  with  any  de- 
gree of  assurance  what  is  really  the  cause  of  this  disease.  As  so 
many  observers  have  found  different  changes  in  different  locali- 
ties of  the  central  nervous  system,  it  may  be  taken  for  granted 
that  the  changes  mentioned  above  are  accidental,  individual 
changes  which  have  little  or  nothing  to  do  with  the  clinical 
symptoms  of  chorea. 

Treatment. — Whatever  view  we  may  take  of  the  origin  of 
chorea,  it  is  probable  that  each  case  has  more  than  one  factor  in  its 
causation,  along  with  varying  individual  susceptibility,  nervous  sta- 
bility, age,  and  season.  Chorea  is,  in  its  manifestation  and  course, 
a  motor  excitability  producing  exhaustion  ;  and  while  usually  ter- 
minating in  full  recovery,  soon  or  late,  nevertheless  a  certain 
number  suffer  recurrences  and  a  few  are  marked  for  life.  If  the 
rheumatic  element  appears  prominently,  as  it  does  in  one-third 
of  all  cases,  exceptional  care  and  imperativeness  must  be  exer- 
cised to  eradicate  it.  Watchfulness  is  needed  lest  it  should  sud- 
denly appear  and  produce  serious  heart-lesion  ;  hence  a  greater 
caution  is  demanded  than  is  generally  enforced.  Moreover,  to 
obtain  prompt  as  well  as  complete  results,  one  may  best  be 
overparticular  and  thorough  in  outlining  and  enforcing  measures 
for  relief.  These  range  themselves  under  five  heads  : 

/.  Specific  -medication,  directed  to  recognizable  conditions,  as 
rheumatism,  malaria,  or  other  infectious  cause,  and  the  empiric 
use  of  arsenic,  the  one  remedy  which  uniformly  yields  good 
results. 

2.  Rest  to  the  body,  which  is  in  extreme  overaction,  whence 
a  reaction  falls  upon  the  motor  centers,  interfering  with  sleep,  etc. 

j.  Nutritional  repair,  necessitated  by  the  many  factors  which 
unite,  in  depreciating  and  devitalizing  the  tissues,  plus  the  wear 
and  tear  from  exaggerated  muscular  action. 

4..  Reeducation  of  coordination,  a  very  important  but  little 
noticed  item. 

5.  To  prevent  recurrence  by  anticipating  the  periodic  return 
and  enforcing  suitable  measures.  Cases  should  return  in  spring 
and  fall,  September  and  February  especially,  to  be  put  upon 
arsenic  in  ascending  doses. 

It  is  assumed  that  we  desire  to  get  the  quickest  and  best 
results. 

First,  then,  whenever  possible,  it  is  well  to  put  the  child  to 
bed  for  a  time,  making  use  of  adequate  clothing  to  prevent 
exposure  and  permitting  play  with  toys  (not  books)  after  a  few 


CHOREA.  533 

days.  The  food  should  be  of  the  plainest  for  a  fortnight  at  least, 
and  altogether  omitting  red  meats.  Nitrogenous  compounds 
are  ever  unstable ;  these  should  be  left  out  in  all  explosive 
conditions,  and  also  to  secure  tranquilization  of  the  excessive 
nervous  discharges.  Sweets  should  be  permitted  only  in  mod- 
eration, using  a  diet  mostly  of  milk,  fruits,  and  vegetables.  The 
child  should  be  bathed  freely  in  tepid  water  twice  a  day,  better 
than  once,  getting  it  cooler  and  cooler.  It  is  well  to  flush  the 
spinal  areas  with  cold  water  from  the  first,  after  the  warm  appli- 
cation has  been  made,  and  use  sharp  friction  to  the  whole  skin 
surface.  If  this  is  done  with  the  dry-salt  towel,  a  better  surface 
glow  is  secured.  A  laxative  every  second  or  third  day  for  the 
first  week  may  be  needed,  to  make  sure  of  freedom  from  intes- 
tinal irritation  or  fecal  toxins. 

Children  suffering  from  chorea  are  usually  pallid  and  often 
found  to  be  anemic  and  flabby.  The  excessive  restlessness  uses 
up  both  nervous  energy  and  blood,  hence  arise  unconscious 
fatigue  and  wasteful  metabolism.  For  this  the  carbohydrates 
offer  better  supply  than  albuminoids,  and  our  custom  is  to 
enforce  the  use  of  fats.  Cod-liver  oil  was  first  used  for  rheumatic 
conditions  and  still  stands  preeminent  as  a  recuperative  agent 
in  disorders  of  this  nature.  It  is  best  given  in  capsule  and  often 
only  once  or  twice  a  day.  Iron  is  not  often  needed,  especially 
when  arsenic  is  employed  for  its  specific  action — whatever  that 
may  be.  For  the  first  fortnight,  bathing  twice  daily,  with  vigor- 
ous salt  towelings,  is  enough  of  tonic  to  the  surface.  After 
that  employ  massage  to  redistribute  blood  from  depths  to  surface 
and  also  for  its  controlling  power  over  nervous  disquietude. 
For  this  effect  it  should  be  administered  somewhat  differently 
from  the  usual  methods  :  slow,  steady  surface-stroking  should 
be  followed  by  firm,  quiet  kneading,  ending  with  passive  move- 
ments of  the  limbs  and  overstretching,  like  that  used  for  spastic 
conditions.  In  children  a  shorter  seance  is  required — not  more 
than  half  an  hour. 

As  soon  as  the  prodigality  of  movements  comes  under  control, 
greater  liberty  may  be  allowed  both  in  diet  and  exercise.  Then 
to  be  partly  dressed  and  remain  up  and  about  the  room  for  most 
of  the  day,  resuming  ordinary  occupations,  is  admissible,  not 
permitting  any  fatigue  production,  however,  and,  above  all,  no 
excitement  or  annoyance. 

When  the  ataxia  has  been  excessive,  a  most  useful  measure  for 
restoring  clean  and  accurate  coordination  is  to  reeducate  the 
limbs  and  motor  centers  by  teaching  the  use  of  accurate  move- 
ments at  word  of  command,  systematic  posings,  and  mild,  free 


534  DISEASES    OF   THE    NERVOUS    SYSTEM. 

exercises.  It  is  well  to  direct  the  action  of  the  eye  up,  down,  to 
right  and  left  ;  the  fundamental  arm  and  leg  attitudes,  rising 
gradually  to  complex  acts,  as  tossing  and  catching  a  ball  or 
bean-bag.  All  this  in  regulated  doses,  and  followed  by  bathing 
and  rest.  In  all  exercises  of  convalescents,  regulated  or  free,  a 
period  of  absolute  rest  should  immediately  follow. 

Of  medicines,  not  a  very  large  variety  warrant  confidence. 
If  any  trace  of  rheumatic  pain  show,  it  is  best  met  by  the  salicy- 
lates,  internally  or  by  inunction,  which  children  bear  very  well 
anyhow,  or  alkalies.  (See  Rheumatism.)  Precede  with  a  laxa- 
tive, and  follow  with  the  arsenic.  Nothing  is  better  than  Fowler's 
solution,  begun  at  three  drops,  thrice  daily,  increasing  one  drop 
a  day  (which  just  doubles  itself  on  the  tenth  day),  and  continuing 
until  toxic  symptoms  are  manifested.  Then  stop  for  one  day,  and 
continue  the  daily  dose  just  preceding  the  toxic  signs  for  several 
days.  If  this  proves  too  much,  stop  and  begin  at  the  three  drops, 
and  go  up  again.  When  movements  have  ceased,  do  not  increase, 
but  keep  on  at  the  dose  of  arsenic  reached  until  a  week  has  passed 
without  twitching.  In  severe  cases  arsenic  may  best  be  given 
hypodermically ;  moreover,  some  will  receive  it  better  thus  than 
by  the  mouth.  For  this  purpose  liquor  potassii  arsenitis  may 
be  made  without  the  lavender.  Arsenic  thus  enters  the  circula- 
tion without  first  passing  through  the  liver,  and  the  poisonous 
effects  are  not  so  readily  produced.  The  arseniate  of  soda  is 
recommended  for  this,  using  a  5  per  cent,  solution,  commencing 
with  three  drops,  gradually  increasing  until  ten  to  fifteen  drops 
are  taken  or  toxic  symptoms  are  produced. 

In  using  Fowler's  solution  always  write  out  the  schedule  of 
increments  on  a  card,  thus  : 

First  day, 3,  3,  3, 

Second  day, 3,  3,  4, 

Third  day, 3,  4,  4, 

Fourth  day, 4,  4,  4,  etc., 

Until  about  the  tenth  day.  Each  day  the  nurse  may  check  off 
the  figures,  showing  the  exact  progress.  It  is  of  value  to 
write  full  directions,  indicating  possible  complications  and  toxic 
symptoms. 

Quinin  has  been  claimed  as  a  specific  upon  the  theory  of 
its  central  action,  reinforcing  inhibition.  It  has,  not  often,  but 
occasionally,  done  good  service  at  our  hands  in  chorea.  The 
possibility  of  malaria  being  at  the  bottom  of  the  disorder  must 
not  be  lost  sight  of,  when,  of  course,  we  may  expect  results 
from  its  use.  Moreover,  quinin  has  a  most  happy  effect  upon 
spasmodic  action,  as  in  pertussis.  In  severe  cases,  when  these 


CHOREA.  535 

measures  fail,  Cheadle  has  recommended  the  hypodermic  use  of 
hyoscin  hydrobromate  twice  a  day,  in  doses  of  from  -^-$  to  -^^rg- 
of  a  grain. 

And,  finally,  chorea  may  pass  into  a  habit  spasm,  although 
that  mimetic  disorder  arises  in  other  ways.  Habit  chorea,  how- 
ever it  may  come,  is  a  close  relative  to  the  real  thing,  and  is 
benefited  by  much  the  same  treatment.  Nevertheless,  it  is  often 
a  most  intractable  condition  and  requires  firm  moral  means  to 
check  it.  Hypnotism,  powerful  suggestion,  and  mild  fright  are 
all  useful.  Suggestion  helps  sensible  children  by  assuring  them 
they  can  become  rid  of  a  foolish  and  entirely  controllable  state. 

The  steam-bath  or  hot  pack,  to  secure  sleep  and  eliminate 
toxins,  has  given  admirable  results  in  certain  cases,  particularly 
when  the  disorder  has  persisted  in  spite -of  rational  treatment. 
This  employed  twice  daily  for  four  days,  without  other  than 
dietetic  treatment  and  laxatives,  then  followed  by  specific  medi- 
cines, has  yielded  excellent  results  in  our  hands. 

In  cases  which  have  had  one  or  more  previous  attacks,  note 
the  months  of  onset,  and  induce  them  to  return  one  month 
earlier  than  the  attacks  occurred  before  for  treatment.  Thus 
they  can  be  practically  aborted. 


HABIT  MOVEMENTS,  HABIT  CHOREA,  OR  Tic. 

Among  the  conspicuous  and  not  rare  disturbances  of  motion 
are  to  be  mentioned  the  habit  movements,  habit  spasms,  or  con- 
vulsive tics  strongly  resembling  chorea,  but  with  special  features 
of  their  own,  and  marked  differences  as  to  nature,  causation,  and 
curability. 

These  are  tricks  of  movements,  coordination  of  muscular  acts, 
generally  involving  the  face,  shoulders,  and  sometimes  legs, 
simulating  purposes,  accompanied  occasionally  by  speech  or 
vocal  and  other  sounds.  In  the  majority  of  cases  they  began  as 
imitations  or  repetitions  of  acts,  becoming  fixed  and  exaggerated 
into  habits,  which  are  difficult  to  cure  in  proportion  as  they  are 
matured,  and  occasionally  persist  throughout  life. 

Probably  the  commonest  starting-point  is  chorea  minor,  espe- 
cially where  the  attention  of  the  child  has  been  drawn  to  some 
particular  movement  or  act  in  another,  and  conscious  or  uncon- 
scious repetitions  have  been  indulged  in  and  then  changed  to 
another  variety  until  a  series  is  formed,  which  performance  is 
repeated  in  succession.  Any  such  trick  should  be  promptly 
recognized  by  parents  and  unqualifiedly  condemned,  nipping 
them  in  the  bud  ere  they  become  an  offense. 


536  DISEASES    OF    THE    NERVOUS    SYSTEM. 

It  is  well  to  use  a  systematic  nomenclature  in  dealing  with 
this  class  of  allied  affections,  which  Osier  says  pass  insensibly 
into  one  another  "  from  a  simple,  habitual,  conscious  spasm  of 
the  facial  muscles  to  complete  coordinate  movements  with 
marked  physical  features,  or  to  habit  phenomena  purely  psychic." 
The  distinguishing  factor  in  the  entire  group  is  the  habit  of 
repetition,  whether  of  motion  or  idea,  which,  while  influenced  or 
controlled  to  some  extent  by  the  will,  occurs  in  response  to  a 
sort  of  impulsion  in  the  case  of  muscular  movements,  and  in  the 
case  of  imperative  ideas  as  a  sort  of  obsession. 

1.  Habit  spasms,  or  simple  tic,  are  the  common  instances  of 
spasmodic  movements,  chiefly  of  the  face  muscles  and  moder- 
ately under  volitional   control.     The  acts    are    repeated    more 
positively  and  with  far  greater  rapidity  than  those  of  chorea ; 
they   are  more    systematic,    purposive,    and    limited    in    scope. 
There  are  cases  of  sudden  contraction  of  certain  muscles  very 
like  that  produced  by  an   electric   shock  ;    hence   Henoch   has 
called  this  electric  chorea. 

2.  Convulsive  tic,  or  Gilles  de  la  Tourette's  disease,  exhibits, 
in  addition  to  the  ordinary  motor  disturbances  of  habit  spasm, 
imperative  ideas  and   explosive,  jerky  shouts  and  ejaculations. 
Some  of  the  words  thus  unintentionally  uttered  or  flung  out  of 
the  mouth  are  accidental  reflections  of  what  has  been   casually 
heard    and    yet    received  a  degree  of    subconscious    attention, 
either  with  a  partly  formed  intention  to  use  again,  or  as  probably 
a  full  intention  never  to  utter :  as,  for  instance,  obscene  phrases, 
of  which  the  patient  may  be  unconscious  or  through  the  use  of 
which  he  becomes  intensely  mortified. 

3.  Complex    Coordinated    Tics    (Noir   from    "  Bourneville's 
Clinic"). — There  are  tricks  of  this  kind  mentioned  by  many, 
several  of  them  being  strung  together  in  a  series  :    as,  a  child 
when  offered  an  object  always  blows  upon  it,  smells  it,  and  turns 
half  away,  or  stooping  down,  lying  on   the  floor,   raising   the 
hands  above  the  head,  etc. 

4.  Psychic  tic,  or  imperative  ideas,  the  outgrowth  from  im- 
perative movements,  the  fixed  idea  impelling  a  child  to  do  certain 
things  under  similar  circumstances,  as  the  old  trick  of  stepping 
on  different  paving-stones  without  touching  the  cracks,  always  to 
go  out  of  the  way  in  passing  certain  objects,  to  cross  the  street 
at  a  certain  place  each  time  in  passing,  etc.     So  strong  are  these 
as  to  make  the  life  of  the  sufferer  a  burden  by  the  multiplicity 
of  the  meaningless  procedures. 

The  treatment  of  these  disorders  is  largely  suggestive. 
Oftentimes  hygienic  measures  are  required,  and  many  of  the 


DISTURBANCES    OF    THE    MIND.  537 


rational  means  outlined  under  the  treatment  of  chorea 
prove  of  value.  Outside  domination  is  generally  required  to 
aid  the  sufferer  to  rid  himself  of  the  disorder.  Partial  hypnosis 
is  most  effective,  prophetic  statements  as  to  when  and  how 
the  recovery  will  recur  (always  indulged  in  with  due  caution 
to  reinforce  probability),  and  dominant  commands  at  times  often 
suffice.  In  spite  of  well-directed  measures  many  cases  persist 
until  death. 

HEREDITARY  OR  HUNTINGDON'S  CHOREA  is  a  very  rare  malady, 
seldom  appearing  in  children,  but  due  to  conditions  chiefly 
hereditary,  which  arise  from  causes  affecting  the  child  in  earliest 
developmental  epochs.  Several  members  of  the  same  family 
are  usually  affected.  The  symptoms  generally  grow  worse  as 
age  advances.  The  movements  of  hereditary  chorea  are  "  coarse 
and  grimacing,  and  may  be  distributed  over  a  large  area  of  the 
body."  They  are  partly  controlled  by  volition  (passive).  In 
true  chorea  the  movements  are  more  localized.  Huntingdon's 
chorea  may  be  confounded  with  posthemiplegic  chorea  or  hemi- 
spasm.  The  reflexes,  however,  are  not  markedly  altered  ;  in  the 
cerebral  disorders  they  are  exaggerated.  Hysteria  may  simulate 
this,  but  exhibits  other  and  characteristic  phenomena. 

Hereditary  chorea  is  incurable  ;  life  is  not  materially  short- 
ened, but  there  is  a  strong  tendency  toward  dementia  in  its  vic- 
tims. Treatment  is  the  same  as  for  true  chorea,  and  the  severity 
of  the  symptoms  can  be  much  mitigated  by  rational  measures. 

POSTPARALYTIC    OR    POSTHEMIPLEGIC    CHOREA    IS    a    choreiform 

disorder  strongly  resembling  chorea  at  times,  but  due  to 
changes  in  the  motor  areas  of  the  brain  and  described  under 
Cerebral  Palsies. 


INSANITY  AND    DISTURBANCES   OF  THE  MIND  IN 

CHILDREN. 

The  subject  of  mental  disorders  occurring  in  children  can  only 
be  treated,  in  a  book  of  this  size,  in  a  general  and  comprehensive 
way.  Systematic  classification  is  of  little  avail,  and  this  will  be 
found  in  special  works  on  the  subject. 

Mental  disorders  in  children  must  of  necessity  be  of  a  simple 
kind,  since  the  intellectual  faculties  are  in  them  not  yet  highly 
specialized.  True  insanity  in  children  has  been  occasionally 
observed  in  the  very  young  ;  even  the  more  conspicuous  kinds, 
as  raving  madness,  have  been  noticed.  It  is  important  to  bear 
in  mind  that  these  mental  disturbances  of  children,  while  at  times 
well  defined,  with  sufficiently  definite  symptoms  to  warrant  both 


DISEASES    OF    THE    NERVOUS    SYSTEM. 

classification  and  definite  prognosis,  nevertheless  change  very 
much  from  time  to  time,  and  that  which  threatened  to  be  serious 
may  subside  most  surprisingly  ;  furthermore,  the  varieties  may 
overlap  considerably,  rendering  a  clear-cut  diagnosis  difficult  or 
impossible.  The  prognosis  in  most  cases  is  to  be  very  guarded 
and  is  usually  good,  provided  the  most  favorable  circumstances 
can  be  secured,  with  wholesome  environment  and  wise  care. 

The  most  important  subjects  for  the  pediatrist  to  study  are 
the  developmental  neuroses,  arising,  as  the  name  implies,  during 
periods  of  growth,  and  their  later  variegated  forms,  resembling 
one  or  another  of  the  recognized  forms  of  insanity  and  hysteria.* 
Some  of  these  pass  readily  away  as  growth  proceeds  ;  others 
become  confirmed  or  change  into  serious  mental  states. 

We  will  give  a  brief  review  of  the  different  forms  of  insanity 
occurring  in  children,  as  outlined  by  Mills  : 

Transitory  Psychoses. — Under  this  head  will  be  considered 
delirium  arising  from  special  causes,  some  children  being  more 
susceptible  than  others  to  mental  perturbations  due  to  slight 
rises  of  temperature.  Some  children  again  have  highly  devel- 
oped imaginations,  and  these,  excited  by  parents  and  others, 
produce  temporary  disturbances  of  mind  which  are  grave  sources 
of  peril  and  readily  productive  of  permanent  states. 

Night-terrors  (pavor  nocturnus)  is  a  form  of  temporary  men- 
tal disturbance.  This  transitory  psychosis  usually  takes  the 
form  of  excited  or  agitated  melancholia,  giving  evidence  of  great 
mental  suffering  and  depression,  vague  and  indescribable.  Day- 
terrors  is  also  recognized,  differing  little  in  clinical  features. 

Mania  is  the  form  of  insanity  most  frequently  occurring  in 
childhood.  It  appears  in  the  form  of  an  active  delirium,  with 
great  motor  excitability,  emotional  expansions  and  hallucinations, 
and  at  times  delusions  in  children  old  enough  to  have  imagina- 
tive ideas.  Mania  may  be  recovered  from  or  become  permanent. 

Melancholia  seldom  begins  before  five  or  six  years  of  age. 
It  usually  merges  into  the  monomanias  and  other  disturbed 
mental  states.  The  varieties  seen  in  children  are  simple  melan- 
cholias, the  excited  or  agitated,  and  the  hypochondriacal.  De- 
pressing surroundings  and  deprivations  sometimes  drive  children 
to  suicide. 

Circular  or  alternating  insanity  is  a  form  in  which  there  is, 
first,  exaltation  or  mania,  followed  by  mental  depression  and 
then  lucid  periods,  and  later  exaltation,  again  to  be  followed  by 
brief  melancholy,  the  cycle  coming  and  going  with  variations. 

*  An  article  on  developmental  neuroses  was  omitted  for  lack  of  space. 


DISTURBANCES    OF    THE    MIND.  539 

Choreic  insanity  is  a  form  of  mental  disturbance  following 
upon  chorea,  which  is  a  variety  so  severe  as  to  exhaust  the 
patient,  interfering  with  sleep  and  health.  It  is  sometimes  of 
a  very  violent  character,  with  great  emotional  exaltation. 

Hysteric  Insanity. — In  childhood  acute  mania  and  hysteric 
mania  run  together  into  a  picture  most  difficult  to  differentiate. 
If  the  characteristic  symptoms  of  hysteria  are  present, — ecstasy, 
catalepsy,  trance,  aphonia,  and  fantastic  emotions  or  false  palsies, 
— there  will  be  little  difficulty  in  distinguishing  between  hysteric 
conditions  and  insanity.  Extraordinary  occurrences  which  have 
given  rise  to  the  suspicion  of  visitation  by  spirits,  by  rappings, 
cat-calls,  rooms  being  set  on  fire,  and  such  like  things  are  very 
likely  to  be  the  result  of  this  form  of  disorder  among  children, 
especially  girls.  Frequently  there  arise  in  institutions  and 
schools  imitative  psychoses,  occurring  in  epidemics  ;  there  are 
then  ordinarily  found  among  the  symptoms  disturbances  of 
speech,  hallucinations  of  sight  and  sound,  and  false  palsies. 

Cataleptic  insanity,  or  catatonia,  is  very  rare  among 
children.  This  form  begins  usually  as  a  mania,  followed  by 
melancholy,  with  stupor,  and  instances  of  dramatic  exhibitions 
following. 

Epileptic  insanity  is  not  rare  in  children  of  well-marked 
imbecile  or  idiotic  characteristics,  and  who  are  the  victims  of 
epilepsy.  Sometimes  attacks  of  insanity  or  mania  occur  among 
children  who  suffer  from  epilepsy,  and  who  in  the  interval 
between  the  attacks  are  apparently  sound  in  mind.  The  mania 
may  occur  just  before  or  after  the  epileptic  paroxysm,  or  replace 
it.  It  should  not  be  a  source  of  surprise  if  epileptic  children 
occasionally  show  marked  perversion  of  character  and  manner. 

Paranoia,  or  primary  delusional  insanity,  is  a  chronic 
form  of  mental  disease,  or,  in  certain  instances,  mere  mental 
instability  accompanied  by  insistent  ideas,  exaggerated  self- 
consciousness  and  perversity  of  character,  and  morbid  impulse. 
Paranoia  is  rare  under  the  age  of  puberty,  but  to  the  trained 
observer  certain  marked  peculiarities  and  eccentricities  will  lead 
him  to  predict  the  development  later,  in  such  defectives,  of 
delusional  insanity.  The  symptoms  are  gross  peculiarities  in 
dress  and  conversation,  obtrusive  ideas  and  egoisms,  tendencies 
to  dreaming  states,  and  a  bustling  attempt  at  remarkable  plans 
leading  to  nothing,  unduly  emphasized  concepts  or  misconcepts, 
with  alternate  periods  of  depression  and  emotional  excitement. 

Moral  insanity  and  moral  imbecility  are  terms  which  are 
needed  to  describe  those  vicious  habits  and  tendencies  constantly 
showing  themselves  in  certain  children  who  are  otherwise  appar- 


54-O  DISEASES    OF    THE    NERVOUS    SYSTEM. 

ently  wholesome  minded.  Instinctive  perversions  and  morbid 
impulses  flow  out  of  some  inherited  constitutional  conditions 
which  are  at  the  root  of  monomania  and  paranoia.  To  estimate 
rightly  such  states  as  these  it  is  necessary  to  understand  fully 
such  words  as  "  concepts,"  which  may  be  morbid  or  imperative  ; 
also  "imperative  movements,"  "insistent  ideas,"  or  unhealthy 
propensities.  The  concept  is  a  definite  or  isolated  thought,  which 
may  become  an  impression  and  tyrannize  the  mind  ;  imperative 
movement  or  action  is  an  unhealthy  impulse,  the  result  of  an  im- 
perative conception.  The  term  "insistent  idea"  is  used  to  de- 
scribe a  habit  of  thought  resulting  from  the  repetition  and  multi- 
plication of  morbid  conceptions,  which  may,  after  a  time,  inter- 
fere with  and  dominate  the  acts  of  volition  and  intellect. 

Morbid  fears,  or  phobias,  are  conditions  occurring  on  the 
borderland  between  mental  health  and  disease,  which  may  be 
transient  or  more  or  less  permanent,  and  generally  have  to  do 
with  hereditary  impressions.  These  may  occur  in  a  mild  form 
and  persist  throughout  a  moderately  useful  life. 

Paretic  dementia  is  essentially  a  disease  of  adult  life,  but  in 
rare  instances  is  seen  in  children. 


IMBECILITY,  FEEBLE-MINDEDNESS,  AND  IDIOCY. 

It  is  important  to  mention  also  the  subject  of  idiocy  and  im- 
becility in  a  work  of  this  character,  to  enable  the  general  prac- 
titioner, who  usually  takes  small  pains  to  investigate  the  subject, 
to  recognize  the  condition  and  early  to  put  the  patient  in  the 
position  to  secure  relief,  repair,  or  at  least  mitigation.  It  must 
not  be  assumed  that,  because  these  conditions,  as  usually  seen, 
are  practically  incurable,  they  need  little  or  no  attention  except 
at  the  hands  of  specialists.  Incalculable  relief  can  be  afforded  to 
many  of  the  victims  of  the  higher  grades  of  imbecility  if  they  re- 
ceive judicious  care  in  their  earliest  formative  periods.  This  is 
important  for  many  reasons,  chiefly  for  the  families  of  such,  who 
will  suffer  far  less  misery  and  discomfort  if  they  are  put  on  their 
guard  and  learn  how  to  manage  the  sufferers  in  the  right  way. 
They  should  learn  to  know  the  limitations  and  not  to  expect 
too  much,  nor  to  inflict  punishment  upon  backward  children  for 
faults  due  solely  to  their  inability  to  form  wholesome  mental  con- 
cepts of  duties  and  responsibilities.  The  imbecile,  moreover,  ex- 
hibits well-marked  characteristics,  a  proper  appreciation  of  which 
will  enable  the  parents  to  educate  him  to  become  an  endurable 
member  of  the  family  or  of  the  community.  Perhaps  the  most 
important  consideration  is  the  question  of  marriage  and  reproduc- 


IMBECILITY,    FEEBLE-MINDEDNESS,    AND    IDIOCY.  54! 

tion,  to  prevent  which  every  effort  should  be  made  and  authority 
exercised.  It  is  of  the  utmost  insistence  that  children  of  obvi- 
ous mental  defects,  even  of  a  relatively  mild  character,  should  be 
removed  from  their  homes  and  placed  in  the  keeping  and  under 
the  guidance  of  those  who  are  competent  to  assume  this  respon- 
sibility. The  machinery  of  an  ordinary  household  is  altogether 
unfitted  to  bear  the  additional  burden  of  these  strange  and  un- 
certain factors. 

The  reason  for  this  bears  equally  upon  the  component  mem- 
bers of  the  household,  on  the  one  hand,  and  the  defective  child, 
on  the  other,  who  is  certain  to  be  made  worse  by  the  overfond 
solicitude  of  a  parent  or  the  impatience  or  harshness  which  is 
more  likely  to  govern  the  actions  of  those  who  must  assume  the 
grievous  burden,  not  knowing  how  it  should  be  borne  nor  how 
the  poor  creature  should  be  managed. 

By  the  term  idiocy  is  meant  a  congenital  absence  of  mentality 
and  intellection.  By  the  term  imbecility  is  simply  meant  an 
arrested  or  partial  development. 

A  child's  mind  may  normally  develop  until  it  reaches  the  age 
of  six  years.  Let  us  now  suppose  that  the  child  ceases  to  de- 
velop mentally  and  intellectually.  At  thirty  years  of  age  we 
would  have  a  creature  whose  mentality  was  six  years  old. 

Again,  imbecility  does  not  of  necessity  indicate  arrest  of  de- 
velopment. A  partial  arrest  of  development  will  cause  an  im- 
becile. 

Imbecility,  feeble- mindedness,  and  mere  backwardness  are 
terms  used  to  denote  the  lesser  degrees  of  mental  deficiency, 
which  run  through  a  very  wide,  varying  scale.  Mere  slowness 
to  acquire  knowledge  is  of  far  less  importance  than  disabilities  of 
judgment  or  lack  of  balance  in  the  reasoning  faculties  necessary 
in  the  ordinary  affairs  of  life.  Where,  as  frequently  happens, 
there  is  conjoined  to  manifest  mental  discrepancies  yet  fairly  large 
capacities  in  certain  lines,  the  difficulties  of  estimation  are  even 
greater.  This  produces  a  state  which  the  world  at  large  is  loath 
to  regard  as  unfit  for  responsibility,  and  yet  none  the  less 
requires  the  exercise  of  safeguards  and  control.  The  inferiority 
of  such  an  individual  is  rarely  detected  in  the  family  circle,  but 
once  the  child  is  thrown  into  competition  with  others  in  the  outer 
world,  its  peculiarities  become  more  or  less  conspicuous.  Under 
these  circumstances  the  feeble-witted  person  becomes  either  the 
butt  or  the  tolerated  one,  is  treated  as  a  creature  apart,  and  fails  to 
grow  in  mind  and  character.  The  imbecile  can  not  appreciate 
the  reason  for  his  lack  of  success,  and  is  incapable  of  developing 
the  higher  moral  ideas  or  faculties,  and  it  is  from  these  defectives 


542  DISEASES    OF    THE    NERVOUS    SYSTEM. 

that  the  mischief-makers  and  criminals  develop,  and  those  in 
whom  the  ideas  of  right  and  wrong  have  never  been  clearly  con- 
ceived or  differentiated.  The  idiot  is  a  much  simpler  problem 
than  the  imbecile.  Being  little  better  than  an  animal,  with  merely 
gross  resemblances  to  a  human  being,  there  can  be  no  question 
that  he  is  unfit  to  be  retained  in  the  family  circle,  where  he 
absolutely  has  no  place,  despite  all  the  well-intentioned  senti- 
ment or  affection  which  may  desire  it.  The  idiot  is  a  person 
who  lacks  capacity  to  form  the  ordinary  mental  concepts  or 
judgments,  and  whose  brain  is  incapable  of  receiving  and  inter- 
preting impressions  from  the  outer  world. 

The  symptoms  of  the  various  kinds  of  mental  defects  in  chil- 
dren would  occupy  too  large  a  space  to  enumerate  thoroughly. 
A  complete  idiot  is  a  human  being  not  only  bereft  of  intellectual 
qualities,  but  without  even  the  intelligence  as  ordinarily  seen  in 
animals.  These  symptoms  run  through  a  very  considerable 
scale,  from  helpless,  speechless  idiocy  up  to  a  type  of  being 
called  "  imbecile."  An  imbecile  is  a  human  being  possessed  of 
the  ordinary  intellectual  faculties,  but  of  a  very  low  order.  This 
definition  is  obviously  lacking  in  definiteness,  but  it  is  scarcely 
possible  to  be  exact.  Beyond  the  imbecile  class  we  reckon 
feeble-minded  and  backward  children,  which  brings  us  up  to  a 
type  merged  imperceptibly  into  the  average  members  of  society. 
The  symptoms  of  the  idiot  are  altogether  apparent :  there  are 
usually  a  general  restlessness  of  movement  and  awkwardness,  a 
ready  excitability  and  irritability  of  temper,  and  peculiarity  of 
facial  expression.  The  question  of  diagnosis  is  usually  whether 
the  mental  deficiency  is  reparable,  capable  of  mitigation  or  cure, 
or  hopeless.  Among  imbeciles  of  the  higher  grades  much  can 
be  accomplished  by  careful  educational  measures  and  firm,  gentle 
control. 

Myxedematous  idiots  and  cretins,  though  extremely  rare  in 
America,  are  interesting,  chiefly  because  of  the  possibilities  of 
cure  which  have  been  opened  up  in  recent  years  by  the  one 
specific  agency  about  which  many  startling  claims  are  made — 
namely,  feeding  with  thyroid  extract.  The  pulverized  gland  is 
now  used  extensively,  and  with  some  brilliant  results  upon  both 
the  mind  and  body.  The  dose  is  from  ^  of  a  grain  to  a  grain, 
three  times  a  day,  for  children  two  years  old,  up  to  two  or  three 
or  even  five  grains  for  older  children.  This  sometimes  produces 
untoward  effects,  which  are  so  obvious  and  varied  that  it  is 
scarcely  worth  while  to  discuss  them  here. 

Treatment  of  Insanity  and  Mental  Disorders  of  Child- 
hood.— In  order  to  prevent  mental  enfeeblement  in  the  young 


"  Or  ('STr 
IMBECILITY,    FEEBLE-MINDEDNESS,    AND    IDIOCY.  543 

we  must  first  defend  them  from  degenerating  influences  of  a  kind 
competent  to  leave  a  permanent  impression  upon  the  individual 
or  the  offspring.  Next,  opportunity  must  be  afforded  for  de- 
velopment of  both  body  and  mind,  which  are  interdependent. 
Again,  protection  must  be  afforded  against  accidental  injury  by 
trauma  or  poisons. 

It  is  rare  to  meet  a  mother  capable  of  rightly  training  a  child 
not  altogether  wise.  Some,  happily,  are  admirably  gifted  in  this 
respect,  and  if  the  mother  is  capable  of  being,  or  will  submit 
herself  to  be,  carefully  instructed  how  such  a  case  shall  be  man- 
aged, sometimes  the  very  best  results  come  from  home  care.  It 
has  been  our  experience  to  see  some  excellent  instances  of  these 
mothers,  and  we  are  inclined  to  believe  that  this  possibility  may 
be  amplified  by  educating  willing  mothers  to  this  duty.  Again, 
we  have  found  immediate  relatives  who  both  could  and  would 
undertake  this  care  and  bring  about  excellent  results.  As  a 
rule,  the  mother  is  so  hampered  by  emotional  considerations 
that  her  judgment  is  not  good  in  respect  to  her  own  child.  Then 
the  question  arises,  To  whom  shall  it  be  committed  ?  It  has 
been  our  custom,  and  we  think  from  it  some  excellent  results 
have  come,  to  always  search  about  among  the  home  possibilities 
of  such  a  case,  and  not  seldom  there  has  been  found  some  good 
maiden  woman  or  widowed  aunt  or  childless  person  who  could 
be  taught  to  do  what  the  same  child's  own  mother  might  be 
able  to  do  for  some  other  woman's  child.  We  have  before  us 
always  the  admirable  example  of  the  insane  colonies  of  Europe, 
where  excellent  results  come  from  treatment  in  private  houses, 
and  whenever  this  can  be  accomplished,  it  is  better  to  do  so. 

In  questioning,  examining,  or  otherwise  dealing  with  the 
child  as  a  neurotic  patient,  success  in  arriving  at  right  con- 
clusions depends  as  much  on  the  demeanor  and  conduct  of  the 
physician  as  on  his  knowledge.  With  the  adult  this  may 
possibly  not  be  true,  but  in  respect  to  the  less  differentiated 
mental  organization  of  the  child  the  proposition  will  hold. 
Skill  born  of  much  experience  is  needed  to  win  the  confidence 
of  the  child,  and  to  this  must  be  added  tact  and  gentleness. 
Here,  again,  gentleness  should  not  lack  firmness  and  decision. 
If  the  patient  is  one  whose  disposition  or  morals  are  obviously 
disordered,  it  is  of  double  importance  to  approach  the  problem 
aright,  either  to  learn  essential  facts  or  to  select  remedies. 

Medicines  are  usually  quite  needless,  but  moral  control  and 
tactful  domination  must  be  ever  forthcoming.  The  physician 
should  succeed  in  impressing  his  personality  upon  the  patient. 
He  must  represent  embodied  power,  helpfulness,  and  justice. 


544  DISEASES    OF    THE    NERVOUS    SYSTEM. 

In  some  instances  he  may  be  of  a  loving  manner,  pleading  with 
the  obstinate  but  sensitive,  errant  nature.  More  often  he  needs 
to  pose  as  a  kindly  yet  overmastering  being,  to  whom  confession 
and  obedience  must  be  yielded  soon  or  late.  Again,  over- 
voluble,  highly  graphic  confessions  of  the  patient  are  to  be 
discounted.  Always  obedience  must  be  exacted,  but  tempered 
by  due  consideration  of  immediate  necessities  and  no  more. 
Gradually  simple  but  systematic  measures  may  be  given  shape 
and  pushed  steadily  to  an  end. 

Much  tactful  shifting  in  the  position  of  the  questioner  is  often 
demanded,  and  seemingly  unessential  procedures  are  at  times 
advisable  ;  patience,  persistence,  and  firmness  always. 

The  heedless  examiner  will  often  give  to  the  shrewd  observa- 
tion of  the  hysteric  or  insane  child  leading  points  on  which  to 
fashion  its  symptom-groups  by  his  idle  words  and  leakage  of 
thought  while  "  thinking  aloud,"  and  he  may  be  thus  misled 
afar.  Moreover,  the  distinction  between  these  closely  resembling 
conditions  is  not  seldom  a  purely  relative  matter,  to  be  decided 
by  the  personal  factor  of  the  observer  or  the  social  'or  individual 
standard  of  the  patient. 

Again,  hysteria  and  organic  brain  diseases  may  coexist,  not 
often  in  the  child,  it  is  true,  but  will  prove  most  puzzling. 

Moral  perversions  are  hard  to  distinguish  from  merely  evil 
and  vicious  tendencies,  which  are  acquired  by  a  stupid,  impres- 
sionable subject. 

The  moral  imbecile  is  inherently  bad  and  practically  incurable. 
He  is  an  instinctive  liar  and  thief,  cunning  and  skilful  in  mischief- 
making,  and  if  in  other  ways  seemingly  competent,  yet  unspeak- 
ably provoking  to  the  teacher  or  parent.  To  know  how  to  deal 
best  with  such  is  generally  conditional  upon  a  clear  decision  as 
to  whether  one  has  to  do  with  an  ineradicable  vice  or  disease 
(here  probably  synonymous)  or  a  possibly  removable  disorder. 
The  main  thing  is  not  to  attempt  for  the  individual  too  elaborate 
a  plan  of  improvement,  and  when  he  is  under  favorable  sur- 
roundings to  exercise  infinite  patience  and  use  abundant  time. 
He  is  to  be  made  to  know  that  while  not  fully  trusted  or  believed, 
the  utmost  encouragement  shall  be  enjoyed  so  soon  as  evidence 
of  improvement  is  shown. 

Along  with  obviously  wicked  acts  may  often  coexist  evidences 
of  disease  processes,  as  convulsions.  It  is  often  most  difficult  to 
determine  surely  whether  these  are  epileptic  or  hysteric.  These 
may  appear  in  combination,  too — hysteric  attacks  in  an  epileptic 
subject,  a  blending  to  which  there  is  no  clear  key. 

Typical,  clear-cut  cases   of  neurotic  maladies    are  none  too 


IMBECILITY,    FEEBLE-MINDEDNESS,    AND    IDIOCY.  545 

common,  and  ordinarily  it  is  only  by  the  after-fruits  of  treatment 
that  they  are  determined.  A  large  familiarity  with  hysteric 
states  increases  one's  respect  for  the  difficulties  of  differentiation. 

Hysteria  must  have  some  sort  of  audience  always,  and  where  - 
ever  vanity  can  be  detected  or  surmised,  it  will  help  to  determine 
the  nature  of  the  attack.  The  instinct  of  the  physician  is  also 
an  aid,  but  must  not  be  masked  by  prejudice. 

In  the  management  and  moral  training  of  children  of  hysteric 
or  maniacal  tendencies  the  first  step  to  be  gained  by  physician 
or  caretaker  is  to  win  their  confidence.  The  best  method  to 
pursue  is  to  show  and  preserve  a  frank,  quiet,  yet  persistently 
friendly  demeanor.  In  first  interviews  it  is  wise  with  all  children 
to  avoid  a  too  direct  and  impulsive  approach.  Childish  concepts 
come  slowly  ;  conclusions  which  are  being  formed  with  no  great 
promptitude  should  not  be  hurried.  Overprecipitancy  offends, 
and  the  result  is  negative.  Very  much  the  same  courteous, 
straightforward  methods  win  a  child  which  prevail  with  the  elder. 

It  is  well  to  efface,  as  nearly  as  possible,  the  differences  of  age 
and  position  between  the  patient  and  physician.  Assume  both 
to  be  on  the  same  plane,  the  one  simply  taking  the  initiative.  It 
is  inscrutable  to  us  how  those  people  who  talk  baby-talk  (as  it 
is  ludicrously  miscalled)  to  children  ever  succeed  in  rendering 
themselves  otherwise  than  most  offensive. 

Knowledge  of  the  mental  processes  of  the  patient  one  must 
have,  and  accurate  information  only  comes  through  intelligent 
questioning.  We  have  repeatedly  been  able  to  secure  the  atten- 
tion and  frank  answers  of  a  child,  which  our  assistants  had 
utterly  failed  to  get,  by  conveying  the  impression  that  we  were 
just  such  a  person  as  themselves,  who  asked  straightforward 
questions  and  fully  intended  to  obtain  equally  candid  replies. 
And  if  this  be  true  of  the  medical  man  in  rare  interviews,  how 
much  more  needful  it  is  that  those  who  watch  and  direct  the 
daily  progress  of  the  child  shall  proceed  in  the  same  frank, 
honest  fashion  ever. 

Punishment  is  sometimes  needed  :  sharp,  corporeal  punish- 
ment, too.  Some  children  of  low  tone  or  vicious  hysteroid 
character  are  amenable  to  no  other  argument.  Who  shall 
administer  this,  and  when,  is  of  gravest  importance  to  determine, 
and  only  harm  comes  of  lack  of  judgment  here.  Oftener  gentle 
domination  or  kindly  encouragement  will  suffice.  A  jocose, 
bantering  tone  also  offends.  Begin  by  questioning  the  attend- 
ant, parent,  or  nurse,  thus  allowing  the  child  to  take  bearings 
and  see  that  you  are  not  an  oger  ;  then  proceed  to  draw  out  the 
childish  thoughts  gently  by  speaking  on  perfectly  comprehensive 
35 


$46  DISEASES    OF    THE    NERVOUS    SYSTEM. 

subjects  first,  and  on  others  indirectly,  and  finally  directly  ques- 
tioning. 

The  children  of  pauper  and  criminal  classes  need  most  careful 
watching  and  unusual  training  in  the  fundamental  principles  of 
morality.  Instead  of  this  they  usually  get  overmuch  liberty 
and  far  too  much  religious  teaching.  The  training  in  religious 
thought  and  observances  has  a  tendency  to  foster  an  exagger- 
ated emotion,  which  is  in  some  ways  closely  allied  to  mental 
and  sexual  excitement.  Moral  instruction  should  always  pre- 
cede the  religious.  Moral  insanity  can  only  be  treated  in  special 
institutions. 

Many  instances  of  juvenile  insanity,  particularly  of  the  type 
of  dementias,  respond  admirably  to  the  use  of  thyroid  extract. 
In  the  melancholias  it  has  proved  of  use,  too.  It  is  worth  an 
empirical  trial  often,  even  though  there  be  no  clear  indication  for 
its  use,  and  the  physician  is  watchful  of  its  effects. 

HYSTERIA  IN  CHILDHOOD  AND  YOUTH. 

The  tendency  during  late  years  has  been  to  make  the  diag- 
nosis of  hysteria  much  less  rashly  than  of  old.  The  time  was, 
and  quite  recently,  when  a  large  number  of  puzzling  functional 
affections  were  called  hysteria  and  treated  as  such.  Increasing 
knowledge  of  the  disorder  is  correcting  this  unfortunate  mistake. 
True  hysteria  frequently  occurs  among  children,  in  whom  it  is 
sometimes  seen  in  a  very  graphic  form,  in  boys  as  well  as  in 
girls,  although  twice  as  frequently  in  the  latter  It  increases 
steadily  in  frequency  of  occurrence  from  the  third  to  the  thirteenth 
year,  and  no  age  is  exempt.  The  popular  idea  of  this  affection 
is  that  it  is  a  mere  feigning  of  disease,  though  hysteria,  while 
simulating  many  disorders,  is  never  a  true  imitation  of  any.  It 
is  a  psychosis  with  clearly  defined  stigmata,  physical  and  psychic. 
Hysteria  may  be  described,  then,  as  a  functional  disturbance  of 
the  nervous  system  due  to  no  known  structural  lesion,  manifested 
by  paralyses,  convulsions,  psychic  and  sensory  disturbances,  and 
impairment  of  vision.  The  early  recognition  of  all  the  neuroses 
of  childhood  is  peculiarly  important.  This  is  especially  true  of 
hysteria,  which,  if  unchecked,  seriously  modifies  character  growth 
and  psychic  development,  as  well  as  obscuring  the  sequelae  of 
acute  diseases. 

In  almost  no  other  disorder  do  we  see  the  influence  of  remote 
causes  so  admirably  illustrated  as  in  the  hysteria  of  children. 
A  neurotic  ancestry  of  howsoever  wide  a  variety  may  be  mani- 
fested in  the  child  in  this  form.  It  is  rare,  if  not  impossible,  for 


HYSTERIA  IN  CHILDHOOD  AND  YOUTH.          547 

children  to  be  thus  affected  unless  there  is  evidence  of  neuro- 
pathic ancestry,  along  with  debilitating  conditions  or  emotional 
strain.  It  readily  happens,  too,  that  a  powerful  example  may 
produce  a  hysteric  outbreak  in  an  apparently  well-balanced  child. 
The  influence  of  environment  is  a  most  potent  factor  in  the  pro- 
duction of  hysteria.  Exciting  causes  are  exhausting  conditions, 
depressed  health  from  acute  diseases,  injuries,  abusive  treatment 
at  the  hands  of  others,  overwrought  emotionality,  and  objection- 
able education  generally,  especially  in  religious  matters.  A  very 
important  study  for  the  general  practitioner  is  to  search  closely 
into  the  hereditary  and  other  causes  of  all  the  neuroses  in  chil- 
dren, and  it  is  also  a  very  essential  part  of  his  duty.  Whenever 
there  is  recognized  ancestral  alcoholism,  insanity,  or  "  marked 
peculiarities,"  the  children  must  be  doubly  watched  and  guarded. 

Hysteric  symptoms  are  frequently  seen  during  convalescence 
from  infectious  and  other  acute  diseases.  Imitative  paralysis, 
contracture,  tremor,  and  persistent  local  pain  or  tenderness  are 
likely  to  follow  various  injuries,  even  very  trifling  ones.  Vexa- 
tions, disappointments,  fright,  shame,  and,  above  all,  religious 
excitement,  are  often  potent  factors  in  the  production  of  psychic 
disturbances.  An  early  encouragement  of  religious  thoughts 
and  training,  especially  of  a  kind  which  cultivates  emotional 
exaltation,  is  powerful  for  harm  in  this  direction.  Perhaps  the 
very  worst  influence  of  all,  because  more  constantly  present,  is 
unwise,  especially  careless,  home  influences,  lacking  in  systematic 
and  watchful  control,  encouraging  selfishness  and  minor  decep- 
tions deemed  necessary  by  the  child  to  secure  what  is  coveted. 
Lax  regulation  as  to  duty  and  the  higher  moral  faculties  is  the 
atmosphere  most  congenial  to  the  growth  of  hysteria  and  even 
worse  things.  However,  it  must  not  be  inferred  that  hysteria  is 
solely  the  outcome  of  individual  blameworthiness,  nor  is  it  always 
the  result  of  lax  moral  conditions  ;  for,  on  the  other  hand,  puri- 
tanic severity  is  capable  of  working  a  large  measure  of  harm. 
Disorders  of  the  generative  organs,  especially  those  resulting 
from  masturbation,  are  important  causative  agents  about  which 
much  might  be  said,  especially  as  parents  are  singularly  unwilling 
or  unable  to  control  habits  of  the  kind  mentioned. 

By  far  the  most  important  element  in  hysteria  is  the  mental 
phenomena,  which  are  exceedingly  varied  and  complex,  and,  to 
a  trained  observer,  capable  of  clear  differentiation,  and  yet,  when 
superficially  studied,  appear  a  mere  mass  of  mental  disturbances, 
imitative  procedures,  pretense,  and  deception.  It  must  first  be 
recognized  that  hysteria  is  not  a  simple  feature  of  degeneracy, 
but  a  condition  which  may  be  acquired  by  children  of  unim- 


548  DISEASES    OF    THE    NERVOUS    SYSTEM. 

peachable  parentage  and  otherwise  excellent  health.  The  child 
subject  to  hysteria  is  markedly  impressionable,  with  a  great  ten- 
dency to  accept  and  act  upon  suggestion.  There  is  a  dissocia- 
tion of  the  higher  mental  faculties,  as  of  volition  and  cerebra- 
tion, from  lower  emotional  and  impulsive  states.  The  actions  of 
a  hysteric  child  during  the  paroxysm  result  from  morbid  con- 
cepts of  associations  of  ideas,  which  permit  the  organic  activities 
to  exhibit  characteristic  irregularities.  The  key-note  to  the 
whole  situation  is  suggestion,  both  in  the  production  of  the  psy- 
chosis and  the  emancipation  of  the  sufferer.  Morbid  suggestion 
from  without  or  within,  one  or  the  other,  or  both,  produces  the 
malady  and  encourages  its  continuance  ;  and  wise,  forceful  sug- 
gestion from  without  will  effect  a  cure,  especially  if  accompanied 
by  well-chosen  auxiliary  measures  systematically  applied. 

The  paroxysm  of  hysteria  consists  of  certain  definite  steps  or 
procedures  which  continue  from  prodromal  states  with  regular 
gradations  to  a  systematic  culmination,  or  they  may  be  checked 
here  or  there,  producing  even  more  extraordinary  features. 

The  paroxysm  or  hysteric  fit  has  acquired  the  reputation  of 
being  the  most  important  manifestation  of  the  disorder,  because 
it  is  the  most  conspicuous.  It  may,  however,  be  absent  or  only 
rarely  observed,  or,  again,  but  atypically  exhibited. 

The  hysteric  paroxysm  usually  begins  with  certain  antecedent 
features,  mostly  changes  in  the  mental  state,  a  shifting  of  the 
mind  from  its  normal  plane.  There  is  never  absolute  uncon- 
sciousness. The  exciting  cause  may  or  may  not  be  apparent ; 
if  not,  the  point  of  departure  of  the  fit  may  be  some  auto- 
suggestion. 

The  fit  follows  close  upon  an  aura,  which  may  be  either  sen- 
sory or  motor.  It  may  begin  abruptly,  or  be  preceded  by 
alternate  laughing  or  crying.  It  usually  begins  with  a  subjective 
feeling,  as  of  a  lump  rising  in  the  throat,  which  is  accompanied 
by  a  sense  of  suffocation.  Another  form  of  aura  consists  of 
loud  noises,  throbbing  or  beating  sounds  in  the  ears ;  still 
another  is  violent  headache,  a  boring  or  piercing  pain,  as  of  a  nail 
being  driven  into  the  head  (clavus  hystericus).  At  other  times 
there  is  dimness  of  vision  or  alarming  dizziness.  Again,  there 
may  be  sensations  connected  with  the  ovaries  or  testicles.  The 
fit  proper  is  usually  divided  into  periods.  The  first  or  convulsive 
period  resembles  epilepsy,  but  is  in  no  sense  identical  with  it. 
The  patient  sinks  down  or  falls  prone  upon  the  back,  with  the 
limbs  extended  and  rigid,  but  with  the  fingers  and  toes  flexed  ; 
the  eyes  are  usually  rolled  slowly  from  right  to  left,  or  crossed  ; 
the  jaws  are  firmly  closed ;  the  breathing  becomes  slow  and 


HYSTERIA    IN    CHILDHOOD    AND    YOUTH.  549 

labored,  and  later  hurried,  the  face  flushed  or  bluish,  the  neck 
turgid  ;  the  cardiac  action  becomes  more  rapid  and  forcible,  and 
consciousness  is  blunted  or  even  almost,  but  never  entirely,  lost. 
Sensation  is  much  obtunded,  and  abolished  in  some  portions  of 
the  body.  Soon  clonic  movements  succeed — a  tremor  affecting 
the  muscles  of  the  trunk,  extremities,  and  face.  This  alternates 
with  electric-like  startings,  during  which  the  patient  may  fling 
himself  furiously  about  or  actually  out  of  bed.  Presently  this 
stage  ends  with  sighs,  and  is  followed  by  a  short  sleep. 

The  next  stage  is  one  of  dramatic  movements,  not  so  com- 
monly seen  here  as  in  Europe.  These  may  appear  by  them- 
selves, and  explain  some  otherwise  puzzling  conditions.  The 
most  common  form  is  a  complete  opisthotonos,  tonic  spasm  of 
the  muscles  of  the  back,  a  bowing  of  the  lumbar  curve  until  the 
child  rests  only  upon  head  and  heels.  This  may  alternate  with, 
or  be  replaced  by,  a  variety  of  quaint  attitudes  and  movements, 
some  of  which  simulate  purposive  acts ;  others  are  merely 
automatic.  The  final  or  closing  period  of  the  convulsive  attack 
is  one  of  delirium.  This  is  usually  an  expression  of  the  domi- 
nating mental  attitude,  and  likely  to  be  reproduced  in  each 
succeeding  fit.  It  usually  expresses  some  condition  of  fear  or 
sadness,  manifested  by  tears  and  sobs  and  more  or  less  incoherent 
appealings  or  pleadings.  The  attack  is  not  always  complete  : 
one  period  may  be  exaggerated  and  the  others  left  out.  Espe- 
cially in  children,  certain  acts  may  be  habitually  performed,  or 
changed  by  suggestion  until  the  combinations  are  most  ex- 
traordinary. 

A  series  of  apparently  purposive  movements  or  merely  auto- 
matic acts  may  originate  in  one  individual,  and  be  so  powerfully 
suggestive  to  others  that  they  unconsciously  imitate  them,  and 
thus  a  wide-spread  contagion  occurs  in  religious  communities  and 
schools,  such  as  gave  rise  to  the  dancing  manias  of  the  Middle 
Ages.  Somnambulism  should  be  mentioned  as  having  points  of 
contact  with  the  hysteric  state.  A  lethargy  also  sometimes  follows 
the  paroxysm.  Catalepsy,  another  psychosis  strongly  resembling 
hysteria,  may  be  observed  during  or  after  the  hysteric  fit.  The 
duration  of  a  paroxysm  may  be  but  a  few  minutes,  and  then, 
with  intervals  of  rest,  be  succeeded  by  others,  as  many  as  two 
hundred  attacks  having  occurred  within  twenty-four  hours  in  a 
case  recorded  by  Sachs  ;  or  it  may  last  longer,  as  in  a  case 
observed  by  the  authors,  in  which  the  attack  continued  for  the 
greater  part  of  two  hours.  Those  which  occur  fragmentarily,  or 
present  considerable  variety  in  their  manifestations,  may  continue, 
with  almost  no  intermission,  day  in  and  day  out,  as  in  the 


55O  DISEASES    OF    THE    NERVOUS    SYSTEM. 

epidemic  which  occurred  in  the  Church  Home  of  this  city  while 
one  of  the  authors  was  on  duty  there. 

The  hysteric  paroxysm,  as  has  been  said,  is  not  the  most 
important  symptom  of  hysteria.  The  permanent  markings 
(stigmata)  of  hysteria  have  to  do  with  changes  in  sensation, 
motility,  the  activities  of  the  viscera,  the  mind,  and  nutrition. 
Alterations  in  sensibility  are  nearly  always  present.  Hyperes- 
thesia  and  local  tendernesses  are  common,  as  in  the  well-known 
hysterogenous  zones.  These  zones  and  areas  of  exalted  sen- 
sation, over  which,  if  pressure  is  made,  pain  is  produced,  and 
some  one  or  other  of  the  more  graphic  motor  manifestations  are 
elicited ;  the  most  common  of  these  are  over  the  ovaries  and 
spine.  In  boys  the  testicles  are  sometimes  hypersensitive. 
Pressure  over  these  zones  may  give  rise  to  a  convulsion,  or, 
again,  may  cause  them  to  stop.  A  hysteric  pain  caused  by  an 
old  injury  may  act  as  a  hysterogenous  zone,  especially  in  one  of 
the  joints,  as  the  hip  or  knee. 

Disturbances  or  alterations  of  sensation  are  characteristic  of 
hysteria.  Anesthesia,  more  or  less  complete,  is  nearly  always 
present  in  the  hysteric  subject,  who  may  often  be  ignorant  of  its 
presence.  Sometimes  this  is  only  of  one  side' -of  the  body, 
divided  with  great  exactness  in  the  middle  line  from  head  to 
heel  (hemianesthesia) ;  and  sometimes  occurs  in  irregularly  dis- 
tributed areas  (disseminated  anesthesia)  ;  or,  again,  is  distinctly 
localized  in  one  arm  or  one  leg  (segmental  anesthesia).  This 
last  may  be  accompanied  by  motor  impairment  (palsy)  of  the 
part.  The  areas  of  anesthesia,  when  pricked,  do  not  readily 
bleed  (ischemia).  The  organs  of  special  sense  are  often  dis- 
turbed in  hemianesthesia,  and  always  upon  the  affected  side. 
Of  these  the  most  important  are  the  eyes  ;  there  may  be  a  con- 
centric narrowing  of  the  visual  field,  or  an  alteration  or  reversal 
in  the  color-fields  (amblyopia  or  color  scotoma).  There  may 
be  deafness  of  one  side,  or  impairment  of  smell  or  taste.  The 
changes  in  the  color-field,  when  characteristic,  are  one  of  the 
most  certain  points  for  differential  diagnosis. 

The  disturbances  of  motility  in  hysteria  are  either  loss  of 
function  (paralysis)  or  perversion  of  function  (contraction  and 
tremor).  These  symptoms  are  very  apt  to  appear  by  themselves. 
The  paralyses  of  hysteria  simulate  those  due  to  central  nervous 
disease  in  their  distribution,  but  not  in  their  clinical  history. 
They  may  be  named  in  the  order  of  frequency  with  which  they 
occur  in  children — viz.,  paraplegia,  monoplegia,  and  hemiplegia. 
The  paralysis  of  motion  is  commonly,  but  not  always,  accom- 
panied by  paralysis  of  sensation.  The  onset  is  usually  sudden, 


HYSTERIA    IN    CHILDHOOD    AND    YOUTH.  551 

and  in  form  may  be  flaccid  or  spastic.  The  immediate  cause  is 
usually  some  emotional  perturbation,  which  may  be  psychic  or 
traumatic.  The  contractures  in  hysteria  may  be  either  partial  or 
complete,  a  local  stiffening  or  a  spasm.  These  contractures  may 
persist  for  years,  though  not  always  constant,  and  sometimes  re- 
turning upon  slight  excitation  ;  they  may  remain  in  the  same  place 
or  pass  from  one  part  to  another.  Tremor  is  rare  in  children  ;  loss 
of  voice  is  not  common,  neither  is  increased  rapidity  of  respiration 
(tachypnea).  Hysteric  vomiting,  also  rare  in  the  young,  is  a 
very  serious  matter  when  it  does  occur,  imperiling  health  or  even 
life.  Its  character  is  siti  generis  a  mere  regurgitation,  due  to  a 
spasm  of  the  esophagus.  The  intestine  is  sometimes  paralyzed 
in  hysteria,  producing  an  immense  bloating,  with  noisy  belching, 
which  is  usually  concomitant  with  a  condition  of  emotional  ex- 
citement. 

Hysteria  is  a  psychosis,  a  profound  disorder  of  functional 
activities,  of  almost  universal  distribution,  but  due  to  no  known 
demonstrable  lesion.  By  some  change  in  mechanism  an  entire 
half  of  the  brain  is  temporarily  invalided,  which  alone  can  explain 
the  complete  hemianesthesia.  The  possibility  of  transferring  this 
anesthesia  from  one  side  to  the  other  would  show  the  two  halves  of 
the  brain  to  be  in  sympathy  one  with  the  other.  The  cortical 
inhibition  is  lessened,  leaving  the  lower  centers  unchecked. 
Recently  expressed  opinions  upon  the  mobility  of  the  neuron 
enable  us  to  reach  a  clearer  understanding  of  hysteric  states,  but 
as  yet  scarcely  explain  the  accompanying  phenomena.  The 
hysteric  child  evidences  a  marked  vulnerability  to  certain  per- 
turbing influences,  is  always  susceptible  to  psychic  changes  and 
functional  disturbance.  The  manifestations  of  the  disease  may 
disappear  during  many  years  and  yet  readily  recur  under  the 
influence  of  slight  morbid  agencies  or  changes  in  condition  or 
emotional  irritation. 

The  treatment  of  hysteria  in  children  or  in  adults  is  always 
complicated  by  the  fact  that  the  causes  which  produce  it  have  so 
much  to  do  with  environment.  It  is  difficult,  almost  impossible, 
to  effect  a  cure  unless  the  unfavorable  environment  is  changed. 
It  is  easy  to  point  out  how  a  case  may  be  benefited  or  cured,  but 
not  so  easy  to  enforce  the  measures  with  sufficient  thoroughness 
to  produce  a  satisfactory  result. 

Bosnia,  in  "The  Paidologist,"  April,  1900,  says:  "Medical 
science  employs  three  methods  in  these  cases:  (i)  The  method 
of  startling :  The  child  is  overpowered  by  a  simple  and  powerful 
command.  (Stand  up  !  Speak  loud  !  Do  n't  cough  !)  There  is 
no  time  left  for  the  child  to  be  ill.  (2)  The  method  of  premeditated 


552  DISEASES    OF    THE    NERVOUS    SYSTEM. 

neglect :  The  doctor  does  not  take  any  notice  of  the  child,  so  the 
child  gets  tired  of  self-thoughts  and  forgets  his  illness.  (3)  The 
method  of  disguised  psychic  means  (hydrotherapy,  electricity,  mild 
corporal  punishment) :  This  therapy  is  based  on  the  faith  the 
patient  has  in  the  treatment.  It  is  more  efficacious  in  adults  than 
in  children.  Electricity  and  cold  water  benefit  children,  inasmuch 
as  the  processes  are  more  or  less  painful.  They  fear  a  repetition, 
and  this  fear  is  often  strong  enough  to  banish  the  pathologic 
ideas  and  the  morbid  symptoms  arising  from  them." 

The  most  important  point  in  treatment,  to  be  always  insisted 
upon,  is  a  complete  separation  of  the  child  from  its  parents  or 
previous  caretakers  during  a  considerable  period  of  time.  The 
physician  finds  himself  in  a  very  difficult  situation,  and  will  usu- 
ally be  compelled  to  compromise.  Indeed,  it  may  sometimes 
be  wiser  to  do  this,  and  then  gradually  lead  up  to  other  measures 
more  and  more  efficient  and  complete.  The  first  part  of  the 
treatment  should  consist  in  the  systematic  application  of  measures 
directed  to  the  improvement  of  general  health,  which  may  not 
seem  obviously  much  impaired.  An  essential  factor  in  the  pro- 
duction of  a  cure  is  a  properly  qualified  nurse  or,  in  rare  in- 
stances, a  wise  and  patient  member  of  the  family  who  can  be 
taught  to  exercise  the  necessary  control.  The  next  most  im- 
portant element  in  the  treatment  is  moral  training,  a  complete 
remodeling  of  the  point  of  view  of  duties  to  self  and  others. 

Bosnia,  op.  cit.,  says  :  "  Wrong  education  is  a  most  powerful 
factor  in  the  causation  of  psychogenic  troubles,  especially  in 
cases  where  a  natural  disposition  toward  them  exists.  If, 
through  wrong  education,  moods  are  not  suppressed,  good 
habits  not  established,  training  of  will-power  neglected,  and  the 
imagination  allowed  to  run  riot,  we  are  in  great  danger  of  culti- 
vating the  neurasthenic  soil  on  which  all  sorts  of  psychogenic 
affections  may  grow  up." 

It  is  of  the  greatest  importance  for  physicians  to  realize  that 
drugs  are  of  no  value  whatsoever  in  the  treatment  of  the  psychosis 
known  as  hysteria.  Judicious  reasoning,  frank  conversation  of 
an  educational  kind,  and  vigorous  suggestions,  with  sometimes 
the  added  pomp  and  circumstance  of  the  proper  place  and  con- 
ditions, are  powerful  agents  for  good.  Thus,  a  steady  repeti- 
tion of  suggestion,  with  judicious  and  thorough  detail,  by  a 
nurse  or  attendant  trained  to  this  end,  is  of  great  efficacy.  As 
soon  as  the  severer  symptoms  are  overcome  and  the  child  re- 
stored to  uniform  good  health,  proper  educational  measures 
must  be  steadily  pursued.  Remedial  measures  directed  to  the 
removal  of  functional  disturbances — for  instance,  hydrotherapy, 


HYDROCEPH  ALUS.  553 

electricity,  especially  the  static  form,  massage,  and  regulated 
exercises — are  of  direct  value.  Strong  faradic  applications  help 
to  overcome  hysteric  paralyses,  particularly  in  conjunction  with 
encouraging  words.  The  manner  assumed  by  the  physician 
exerts  the  utmost  influence  for  good  or  evil.  A  frank,  candid 
exposition  of  the  patient's  need  should  be  clearly  given.  The 
medical  man  should  be  recognized  by  the  patient  as  most  kindly 
disposed,  encouraging,  and  yet  relentlessly  firm. 

For  the  sensory  disturbances  the  cold  douche,  or  alternate 
use  of  hot  and  cold  water,  or  the  employment  of  some  of  the 
more  picturesque  devices,  such  as  metallotherapy,  may  prove 
beneficial.  Hypnosis  will  control  a  certain  proportion  of  phe- 
nomena, and  is  rather  easy  to  produce  in  children,  who  at 
best  are  very  impressionable,  but  is  little  better  than  repeated, 
direct  suggestion  at  the  hands  of  a  physician  whom  the  child 
has  learned  to  respect  and  esteem.  To  overcome  a  paroxysm 
or  convulsion  the  following  measure  may  prove  efficient :  Iced 
water  dashed  repeatedly  over  the  face  or  back,  or  trickled 
steadily  upon  one  point,  as  from  a  small  hose  or  watering-pot ; 
pieces  of  ice  rubbed  here  or  there  on  the  back  or  chest,  and 
lastly,  inhalations  of  ammonia  or  nitrite  of  amyl.  Pressure  over 
ovarian  region  or  in  inframammary  regions,  likewise  pressure 
over  the  vertex,  sometimes  stops  grave  attacks. 

HYDROCEPHALUS. 

Clinically  hydrocephalus  is  the  accumulation  of  an  excessive 
amount  of  serous  cerebrospinal  fluid  within  the  cranium,  and  is 
divided  into  external  hydrocephalus,  where  the  collection  is 
beneath  the  dura  and  outside  of  the  brain,  and  internal,  where 
the  ventricles  are  overdistended,  and  these  two  conditions  may 
coexist.  The  distinction  is  further  made  between  acute  and 
chronic  hydrocephalus.  The  effusion-  is  either  slow  and  passive 
or  rapid  and  due  to  irritation.  The  acute  form  is  rare.  Some 
form  of  hydrocephalus  accompanies  all  the  varieties  of  menin- 
gitis, especially  the  tubercular ;  but  there  is  a  particular  disease, 
described  by  Quincke,  called  meningitis  serosa,  and  considered  a 
purely  idiopathic  serous  meningeal  inflammation.  The  cause  of 
this  may  be  due  to  injury  and  the  sequel  of  various  febrile  dis- 
eases and  certain  other  agencies  which  profoundly  disturb  the 
circulation,  as  the  overuse  of  alcohol  in  the  parents. 

The  symptoms  of  acute  hydrocephalus  are  very  similar  to 
those  of  an  acute  meningitis — retraction  of  the  head,  rigidity, 
nausea,  coma,  delirium,  sometimes  fever  up  to  103°  F.,  sluggish 


554  DISEASES    OF    THE    NERVOUS    SYSTEM. 

pupillary  reaction,  with  inequalities,  and  optic  neuritis.  In  mild 
cases  these  phenomena  soon  subside  and  full  recovery  follows. 
This  is  what  frequently  gives  rise  to  the  cerebral  symptoms  which 
accompany  the  acute  febrile  diseases.  At  other  times  the  disease 
progresses  to  a  fatal  issue. 

Chronic  hydrocephalus  may  begin  as  a  congenital  imperfection 
of  the  brain,  due  to  lack  of  proper  development.  This  may  be  con- 
fined to  one  hemisphere,  the  whole  of  which  may  become  a  huge 
cyst  communicating  with  the  ventricles.  The  most  important  form 
of  hydrocephalus,  however,  is  the  congenital.  Here,  during 
intra-uterine  life,  the  ventricles  become  distended  with  a  large 
amount  of  fluid,  which  so  increases  the  size  of  the  head  as  to 
cause  an  impediment  or  a  bar  to  a  normal  parturition  ;  or,  the 
child  surviving,  the  fluid  may  go  on  increasing  for  days,  or  to  the 
end  of  quite  a  long  life.  Such  a  child  may  be  born  of  apparently 
perfectly  healthy  parents,  and  there  may  be  more  than  one  like 
this  in  a  family.  The  actual  cause  is  seldom  known,  but  the 
various  degenerative  conditions  in  the  parents  are  accredited  with 
causal  agency,  and  no  doubt  are  more  or  less  operative.  Pro- 
foundly disturbing  causes  acting  upon  the  mother  are  probably 
competent  to  produce  a  condition  of  this  kind,  but,  as  a  rule,  only 
where  other  causes  coexist  in  one  or  both  parents,  as  syphilis, 
tuberculosis,  and,  above  all,  alcoholism.  Mild  congenital  hydro- 
cephalus is  probably  quite  common,  and  recovery  is  oftentimes 
so  complete  that  mental  development  is  little  or  not  at  all  inter- 
fered with.  It  is  true  that  the  growth  of  the  brain,  under  the 
grave  disadvantages  of  this  internal  hydraulic  pressure,  met  by 
the  resistance  of  the  cranial  walls,  is  usually  so  interfered  with  as 
to  produce  varying  degrees  of  imbecility.  The  brain  itself  may 
become  distorted  and  reduced  to  thin  sheets  here  and  there,  the 
white  matter  yielding  more  readily  than  the  gray,  and  yet  it  is 
astonishing  how  fair  a  degree  of  integrity  of  functional  activity 
it  may  retain. 

The  diagnosis  of  different  forms  of  hydrocephalus  is  very 
difficult  and  not  of  much  practical  importance.  If  the  child  is 
of  good  vigor,  it  may  survive  and  acquire  a  fair  degree  of 
intelligence ;  if  not,  it  will  speedily  succumb  to  very  slight  dis- 
turbances. Regular  measurements  will  enable  the  physician  to 
estimate  the  increase  in  the  fluid  and  thus  determine  the  course 
of  the  disease. 

Treatment  is  by  no  means  hopeful.  In  the  milder  cases 
iodids  and  tonics  may  do  some  good,  along  with  mercurials  and 
diuretics.  The  tapping  of  the  ventricles  has  been  advocated 
and  is  a  safe  enough  procedure,  but  the  accumulation  of  fluid 


EXOPHTHALMIC    GOITER.  555 

is    so    rapid  that   there   is   little  to   encourage   tne  use  of  this 
measure. 

Lumbar  puncture  is  a  simple  operation  capable  of  small  harm, 
and  is  often  of  much  use  in  the  acute  forms.  We  have  re- 
ported three  cases  markedly  benefited  by  lumbar  puncture,  one 
permanently,  and  in  two  the  acute  overwhelming  phenomena  of 
hydrops  cerebri  were  satisfactorily  mitigated. 

EXOPHTHALMIC   GOITER. 

This  disease,  known  as  Graves'  thyroid  disease  by  the  English 
and  as  Basedow's  disease  by  the  Germans,  is  confined  chiefly  to 
adults,  but  begins  occasionally  in  childhood.  Moreover,  it  is 
necessary  to  distinguish  between  this  and  an  enlargement  of  the 
thyroid  gland,  and  also  certain  disturbances  in  the  cardiac  rhythm 
seen  in  girls  at  or  near  puberty.  Again,  there  are  other  instances 
of  tachycardia,  usually  transient,  but  occasionally  most  persistent 
and  confusing,  as  in  the  case  of  a  boy,  a  patient  of  one  of  us, 
which  baffled  the  skill  of  many  physicians,  finally  getting  well 
of  itself  in  spite  of  overmuch  medication.  The  most  frequent 
cause  is  excessive  emotional  excitement,  but  this  is  usually  super- 
added  to  some  other  exhausting  disturbance,  and  the  whole  upon 
a  basis  of  neurotic  heredity.  Rheumatism  and  typhoid  fever 
have  been  quoted  as  causes,  and  statistics  show  a  goodly  number 
of  rheumatics  among  exophthalmic  goiter  patients.  The  thyroid 
gland  is  accused  of  being  responsible  as  the  cause,  by  an  irregular 
or  deficient  action,  producing  a  toxin  affecting  vascular  inner- 
vation. 

The  symptoms  of  exophthalmic  goiter  are  rather  numerous. 
The  three  classical  symptoms  are  :  Irregular  and  overmuch  action 
of  the  heart  (tachycardia),  enlargement  of  the  thyroid  gland,  and 
protrusion  of  the  eyes.  There  are  certain  accessory  symptoms, 
the  most  important  of  which  are  connected  with  a  disturbance 
of  vasomotor  control.  The  skin  is  usually  much  relaxed,  and 
there  is  almost  constant  sweating,  sometimes  excessive,  which 
may  be  localized  or  general.  There  is  often,  too,  an  apparently 
causeless  diarrhea,  seemingly  independent  of  intestinal  distur- 
bance, most  difficult  to  control.  The  kidneys  frequently  suffer 
in  the  same  way,  as  shown  by  albuminuria  and  occasional  hema- 
turia.  In  some  instances  sugar  appears  in  the  urine  also.  There 
is  occasionally  disturbance  of  respiration,  and  attacks  resembling 
asthma  occur. 

The  most  important  symptom  is  the  disturbance  of  the  action 
of  the  heart,  which  can  scarcely  be  called  organic,  although  when 


556  DISEASES    OF    THE    NERVOUS    SYSTEM. 

unduly  prolonged,  it  may  give  rise  to  dilatation  or  even  hyp*--/- 
trophy.  The  sounds  of  the  heart  are  not,  as  a  rule,  altered,  but 
may  be  unusually  loud,  and  musical  murmurs  at  the  base  have 
been  described.  The  pulse  oftentimes  runs  very  high,  especially 
under  excess  of  excitement  or  slight  exertion.  Hemorrhages, 
as  from  the  nose,  are  not  infrequent,  also  into  the  alimentary 
tract.  One  of  us  has  paid  a  good  deal  of  attention  to  this  dis- 
ease, especially  in  adults,  and  several  cases  have  been  observed, 
especially  in  young  girls,  which  seemed  to  be  instances  of  this 
disorder,  but  exceedingly  mild.  In  some  of  these  the  tachy- 
cardia was  absent  or  only  occasionally  present,  but  the  enlarge- 
ment of  the  thyroid,  exophthalmos,  the  leaking  of  the  skin, 
attacks  of  dyspnea  and  tremor,  especially  a  vibratile  quality  of 
the  voice,  were  all  observed.  The  enlargement  of  the  thyroid 
gland  is  usually  present,  but  the  other  symptoms  may  exist  with- 
out it.  It  is  likely  to  follow  the  development  of  the  tachycardia. 
The  bronchocele  is  generally  of  both  sides,  but  one  side  is  usually 
bigger  than  the  other.  The  exophthalmos  is  less  constantly 
present  than  the  tachycardia  or  goiter,  and  while,  as  a  rule,  of  both 
eyes,  may  be  unilateral  or  more  marked  on  one  side  than  the 
other.  The  cause  of  this  is  probably  interference  with  the  venous 
currents,  along  with  arterial  congestion.  It  disappears  almost 
immediately  after  death.  Vision  is  rarely  interfered  with.  The 
pupils  may  be  unequal,  but  of  normal  reaction.  Von  Graefe's 
symptom,  long  regarded  as  of  importance  (a  failure  of  the  upper 
lid  to  follow  promptly  the  downward  movement  of  the  eye),  is 
by  no  means  constantly  present,  and  may  occur  in  connection 
with  other  neuroses.  There  are  often,  in  addition  to  these  phe- 
nomena, evidences  of  mental  disturbance  or  loss  of  equilibrium, 
commonly  present  at  some  stage  of  the  disease.  Patients  with 
Graves'  thyroid  disease  are  usually  irritable  and  fretful,  but  this 
is  not  to  be  wondered  at  when  one  reflects  how  annoying  it  is, 
when  feeling  in  other  ways  pretty  well,  to  be  constantly  limited  in 
normal  energies,  to  find  one's  self  unable  to  sustain  any  ordinary 
activity  without  prompt  distress.  Headache  is  a  not  uncommon 
feature. 

The  morbid  anatomy  of  Graves'  disease  is  far  from  being 
understood,  and  the  theories  regarding  pathology  are  still  most 
conflicting.  Views  as  to  the  toxic  origin  of  the  disease,  based 
upon  deficient  or  perverted  action  of  the  thyroid  gland,  obtain 
rather  generally.  Graves'  disease  runs  a  chronic  course  for 
months  or  many  years,  but  the  prognosis,  in  our  opinion,  is 
good.  We  have  seen  a  number  of  cases  become  most  comfort- 
able, and  several  very  severe  ones  become  entirely  cured. 


RAYNAUD'S  DISEASE.  557 

Treatment. — There  is  no  reason  to  believe  that  we  have 
found  any  specific  for  this  disease.  Certainly  our  own  experience 
in  the  use  of  thyroid  extract  has  proved  disappointing.  The  use 
of  some  other  of  the  animal  extracts  may  yet  prove  curative. 
The  extract  of  suprarenal  capsule  has  given  good  results.  A 
removal  of  some  part  of  the  enlarged  thyroid  is  a  much  more 
rational  measure,  and  yet  in  most  instances  unnecessary.  Our 
opinion  is  that  this  is  a  most  manageable  disorder,  and  in  fully 
half,  if  not  more,  of  the  cases  entirely  curable.  Attention  should 
be  directed  first  to  the  vascular  erethism,  by  absolute  rest  in 
bed,  at  least  for  a  few  weeks,  with  graduated  return  to  activities  ; 
uniformity  in  diet,  at  first  milk  or  its  equivalent ;  careful  atten- 
tion to  digestion  and  elimination  ;  and  agents  which  will  tran- 
quilize  and  control  cardiac  action.  Small  repeated  doses  of 
hyoscin  hydrobromate  have  given  us  the  best  results  as  a  tran- 
qulizer  and  vascular  control  agent,  along  with  phosphate  of  soda 
or  the  glycerophosphates,  and  from  time  to  time  the  use  of  the 
direct  cardiac  tonics,  of  which  digitalis  is  the  most  satisfactory. 
For  the  sweating,  a  distressing  symptom,  if  hyoscin  hydrobro- 
mate fails  to  control  this,  picrotoxin  acts  admirably,  from  y-^  to 
-jig-  of  a  grain,  as  often  as  may  be  needed  to  produce  an  effect. 
In  the  vasoconstrictor  action  and  especially  where  there  is 
defective  vasoresistance,  the  use  of  Merck's  digitalin  is  of  great 
value,  in  ascending  doses  until  results  are  secured.  Baths  and 
frictions  are  important,  especially  salt,  as  sea-water.  As  a  direct 
application  to  the  skin  aromatic  vinegar  is  pleasant  and  effective. 
Cold  to  the  region  of  the  heart  will  control  tachycardia.  For 
the  diarrhea,  opiates  and  the  aromatic  sulphuric  acid  are  useful, 
and  cannabis  indica,  with  caution  ;  sometimes  small  repeated 
doses  of  podophyllin  act  even  better  than  astringents.  Bella- 
donna and  hyoscin  are  helpful  in  most  stages  of  the  disorder,  as 
well  as  alkalies,  uricacidemia  being  a  pretty  common  collateral 
factor.  The  main  reliance  is  upon  general  hygienic  measures. 
Other  glandular  extracts  are  praised  for  their  effects  on  this 
disease,  notably  that  of  the  adrenals. 

RAYNAUD'S  DISEASE. 

Raynaud's  disease,  called  also  symmetric  gangrene,  is  a  tro- 
phoneurosis  occurring  rarely,  but  the  sufferers  are  quite  as  often 
children  as  adults.  This  disease  consists  of  a  localized  ischemia 
or  asphyxia,  symmetrically  distributed.  The  parts  affected  are 
pale  and  wax -like  in  appearance,  greatly  increased  by  variations 
in  temperature,  as  when  dipped  into  cold  water.  The  local  tern- 


558  DISEASES    OF    THE    NERVOUS    SYSTEM. 

perature  is  lowered,  and  if  the  part  is  pricked,  little  or  no  blood 
comes  from  the  puncture.  The  regions  affected  are  the  fingers 
and  toes,  the  nose,  and  sometimes  the  buttocks  and  calves.  The 
disease  may  remain  slight  and  the  parts  recover  their  tone.  In 
other  instances  the  disorder  progresses  and  gangrene  results, 
producing  a  destruction  more  or  less  extensive. 

Causes. — Raynaud  states  that  the  cause  for  the  disease  is  a 
condition  of  arterial  spasm.  This  theory  is  a  perfectly  possible 
explanation  of  the  condition,  but  some  underlying  cause  must 
be  present  to  bring  about  the  vasomotor  difficulty.  Other 
observers  believe  the  phenomena  due  to  an  obliterating  end- 
arteritis. 

The  symptoms  of  Raynaud's  disease  have  been  noted  in 
connection  with  neuritis  and  myelitis,  locomotor  ataxia,  and 
syringomyelia. 

The  prognosis  as  to  life  is  fair.  If  the  disease  destroys  tissue 
extensively,  the  general  health  suffers. 

Treatment  is  mainly  the  raising  of  the  plane  of  the  patient's 
health.  Galvanism  and  faradism  are  used, with  good  results, 
and  nitroglycerin  in  ascending  doses  at  times  is  efficacious.  A 
prompt  removal  of  the  gangrenous  parts  is  indicated. 

MYXEDEMA. 

Myxedema  may  be  described  as  a  condition  of  ill  health  mani- 
festing itself  by  a  series  of  symptoms  of  malnutrition.  It  is 
a  trophoneurosis  allied  to  cachexia  strumipriva  and  sporadic 
cretinism,  which  has  obtained  much  attention  of  late  because  of 
the  brilliant  results  of  thyroid  feeding,  relieving  what  had  always 
been  considered  an  incurable  and  deplorable  state. 

The  cause  of  this  is  a  lowered  or  altered  activity  in  partly 
diseased  states  of  the  thyroid  glands,  the  degree  of  severity 
being  conditional  upon  the  extent  to  which  the  destruction  of 
the  secreting  portion  of  the  gland  in  question  has  occurred. 
Menke  asserts  it  is  also  a  disease  of  the  vascular  system,  with  its 
characteristic  phenomena.  Vermehran  believes  that  old  age  is  a 
chronic  myxedema  and  that  the  disease  in  the  young  is  a  prem- 
ature senility. 

The  symptoms  of  the  congenital  form  are  :  A  hard  and 
glossy  skin,  stunted  stature,  a  mental  state  of  more  or  less 
complete  idiocy  or  imbecility,  with  lips  and  tongue  thick  and 
large,  a  subnormal  temperature,  and  great  intolerance  of  cold. 
The  general  appearance  of  a  child  so  affected  is  characteristically 
loathsome.  Happily,  immense  improvement  is  to  be  expected 


MIGRAINE.  559 

from  a  gradual  use  of  feeding  with  thyroid  extract,  ^  to  one 
grain  once  or  twice  a  day,  cautiously  increased  until  three  to  five 
grains  twice  a  day  may  be  taken.  How  large  an  improvement 
can  be  had  our  experiences  in  the  matter  do  not  as  yet  enable  us 
to  judge.  Bruns,  of  Tubingen,  after  relating  the  good  results  in 
a  number  of  cases  of  goiter,  says  the  results  of  thyroid  feeding 
are  especially  conspicuous  in  children. 

MIGRAINE. 

Migraine,  megrim,  hemicrania,  or  sick  headache  is  an  exceed- 
ingly troublesome  neurosis  of  young  people,  and  occurs  fre- 
quently in  children.  It  is  characterized  by  occasional  attacks 
of  headache,  often  of  one  side,  with  which  are  associated  nausea 
or  vomiting  and  peculiar  visual  disturbances,  vertigo,  and  some- 
times alterations  of  sensibility. 

Causes. — Migraine  is  usually  inherited,  either  in  its  own  form 
or  as  an  outbreak  of  a  tendency  to  neuroses,  among  which  epi- 
lepsy and  hysteria  are  prominent.  The  disease  usually  begins 
early  in  life,  most  cases  between  twenty  and  thirty,  but  some 
between  the  fifth  and  the  tenth  years,  and  more  frequently  in  the 
female  sex.  Exciting  causes  are  emotional  disturbances,  worri- 
ment,  fatigue,  and  disorders  of  digestion. 

The  predisposing  causes  of  migraine  are  overwork,  anemia,  and 
general  debility,  which  latter  may  be  primary  or  be  the  sequel  of 
some  constitutional  disease,  not  infrequently  the  acute  infections. 

Symptoms. — The  attack  may  come  on  rather  slowly  or  quite 
suddenly,  by  a  physical  depression  more  or  less  obvious,  pallor, 
chilliness,  or  disturbance  of  sight ;  then  comes  the  head-pain, 
gradually  increasing,  for  a  few  hours  only  or  for  a  whole  day. 
Vomiting  or  nausea  usually  accompanies  the  headache,  but  this 
may  also  be  absent,  or  the  nausea  may  be  present  and  the  head- 
ache absent — this  especially  in  atypical  attacks.  Irregularities  in 
the  train  of  symptoms  are  more  likely  to  be  seen  in  younger 
children,  increasing  in  severity  and  completeness  of  the  clinical 
picture  as  puberty  approaches,  after  which  time  it  usually  persists 
until  early  middle  life,  when,  happily,  it  not  seldom  disappears. 
The  most  characteristic  phenomena  are  the  unilateral  headache, 
the  sudden  and  extensive  pallor,  and  the  visual  symptoms,  often 
transient  hemianopsia  or  hallucinations  of  sight.  The  nausea  and 
vomiting  are  very  like  that  due  to  cerebral  irritation,  and  some- 
times mark  the  culmination  of  the  attack,  followed  by  relief,  and 
sometimes,  again,  it  is  not ;  but  the  pain  and  the  vomiting  may 
continue  uncontrollable,  until  the  sufferer  longs  for  death.  The 


560  DISEASES    OF    THE    NERVOUS    SYSTEM. 

most  interesting  symptom  is  the  visual  disturbance,  coming  on 
sometimes  at  the  very  beginning,  or  persisting  throughout  the 
attack.  This  may  appear  as  flashes  of  lightning  for  the  first 
symptom,  startling  the  patient.  Others  see  bright  zigzag  lines, 
balls  of  fire,  or  figures  of  different  shapes,  the  same  sometimes 
recurring  in  subsequent  attacks  ;  others  suffer  more  or  less  loss 
of  sight,  sometimes  complete  blindness  or  intense  photophobia. 
The  vasomotor  phenomena  are  often  prominent :  usually  pallor 
of  the  surface  and  coldness  of  the  extremities,  or  the  surface  may 
be  extremely  flushed,  and  these  may  alternate  in  the  same  attack. 
When  the  explosion  has  spent  itself,  there  follows  a  considerable 
exhaustion,  as  a  rule,  yet  in  other  cases  the  patient  feels  storm- 
swept  and  relieved.  There  are  many  things  in  the  attack  which 
resemble  the  explosion  of  an  epileptic  paroxysm  ;  but  unlike  the 
latter,  which  tends  to  get  worse,  migraine  is  ultimately -outgrown, 
as  a  rule,  and  the  sufferer  does  not  exhibit  the  marks  of  a  degen- 
erate. The  attacks  are  apt  to  recur  with  more  or  less  regular 
periodicity. 

Pathology. — The  pathology  of  migraine  is  not  known.  It  is, 
however,  a  cerebral  affection  closely  allied  to  a  sensory  epilepsy. 
There  is  every  reason  to  believe  that  changes  in  th'e  blood  supply 
of  the  brain  or  its  coverings  are  primarily  responsible  for  the 
symptoms  of  migraine,  and  that  the  sympathetic  nervous  system 
is  largely  involved.  In  addition  to  the  view  of  its  vasomotor 
origin  some  observers  argue  that  there  must  be  an  inherent 
alteration  of  the  nerve-cells  of  the  brain.  It  is  a  curious  fact 
that  whereas  in  a  person  subject  to  migraine  changes  in  the  vaso- 
motor apparatus  are  capable  of  producing  this  nerve  storm,  yet 
in  one  without  this  tendency  no  such  effect  is  produced.  The 
resemblance  between  migraine  and  epilepsy  is  so  close  that  they 
may  represent  different  degrees  of  affection  of  the  cortical 
structure.  Again,  it  may  be  the  effect  of  differences  in  the 
amount  and  quality  of  the  secretion  of  certain  glands,  as  of  the 
thyroid,  adrenals,  or  spleen. 

Great  care  should  be  exercised  in  the  examination  lest  some 
cases  of  migraine  be  met,  not  so  typical,  which  may  be  confused 
with  what  will  prove  to  be  a  trifacial  neuralgia. 

Treatment. — For  the  treatment  of  the  attack  very  little  can 
usually  be  done  that  is  at  all  satisfactory.  The  stomach  usually 
empties  itself,  and  it  is  difficult  to  administer  medicines  which 
shall  be  retained  by  that  organ.  Hypodermically  many  drugs 
can  be  given  which  relieve ;  of  these,  small  doses  of  atro- 
pin,  hyoscyamin,  or  hyoscin  hydrobromate,  from  ^-^  to  yi^ 
of  a  grain,  are  useful.  The  nitrates  have,  in  our  experience, 


NEURITIS.  56l 

given  satisfaction  ;  nitroglycerin,  -^^  to  T^  of  a  grain,  along 
with  hyoscin  hydrobromate,  has  afforded  in  our  hands  much 
relief.  If  the  stomach  will  retain  them,  a  host  of  remedies  may 
be  tried,  some  one  or  few  of  which  may  be  found  to  relieve  the 
individual  case. 

One  of  the  best  remedies  for  some  is  an  infusion  of  black  coffee, 
without  sugar  or  milk.  Elixirs  and  syrupy  things  are  liable  to 
disturb  digestion,  already  imperiled.  Powders  or  plain  solutions 
of  the  coal-tar  derivatives  suit  some  people ;  and  a  mixture  of 
phenacetin,  three  grains  ;  caffein,  one  grain  ;  codein,  ^  grain  ; 
bicarbonate  of  soda,  five  grains,  repeated  every  hour,  is  beneficial 
in  some  cases.  Nitroglycerin  or  the  hyoscin  salts  may,  one  or 
both,  be  given  with  this,  and  if  the  heart  is  quite  weak,  three  to 
five  drops  of  tincture  of  strophanthus  ;  aconite  is  too  depressing. 
In  some  cases  a  small  quantity  of  alcohol  is  of  use — a  teaspoon- 
ful  or  two  of  brandy  ;  this  is  not  to  be  encouraged.  Aromatic 
ammonia  relieves  some  instances,  especially  if  the  stomach  is 
overacid.  It  is  best  to  avoid  strong-tasting  preparations. 

The  constitutional  treatment  of  sufferers  from  migraine  must 
receive  careful  attention.  Examination  of  the  eyes  and  proper 
correction  of  refraction  errors  may  happily  relieve  in  some  cases. 


NEURITIS. 

It  is  only  recently  that  the  subject  of  inflammation  of  the  nerves 
has  begun  to  be  recognized  or  understood,  yet  the  importance  is 
very  great. 

MULTIPLE  NEURITIS. 

Multiple  neuritis  or  polyneuritis  is  a  term  used  to  describe  an 
acute  inflammatory  disease  of  the  peripheral  nerves  and  nerve- 
trunks,  characterized  by  pain,  anesthesia,  paresthesia,  paresis,  and 
muscular  atrophy. 

Causes. — Multiple  neuritis  is  relatively  infrequent  in  children, 
since  the  causes  leading  to  it  are  much  more  prevalent  in  adult 
life.  The  common  causes  for  multiple  neuritis  are  poisons  of 
various  sorts  which  exhibit  a  selective  tendency  to  affect  the 
peripheral  nerves.  Perhaps  the  commonest  of  these  affecting 
children  are  the  toxemias,  due  to  the  ravages  of  micro-organisms 
of  the  infectious  diseases,  tubercle,  and  the  like  ;  this  may  also 
be  due  to  sepsis,  which  follows  in  the  wake  of  injuries  of  many 
sorts.  The  malarial  poison,  due  as  it  is  to  a  specific  organism, 
plasmodium  malariae,  has  been  recognized  as  a  cause  in  a  number 
of  instances.  These  cases  are  sometimes  mistaken  for  polio- 
36 


562  DISEASES    OF    THE    NERVOUS    SYSTEM. 

myelitis,  but  are  usually  associated  with  intermittent  fever, 
during  which  the  disease  undergoes  remissions.  Examination  of 
the  blood  and  spleen  will  reveal  the  cause,  and  quinin  produces 
a  relatively  swift  recovery.  The  infectious  diseases  commonly 
give  rise  to  forms  of  peripheral  neuritis  ;  especially  is  this  notice- 
able since  our  recent  visitations  of  epidemic  influenza.  Diph- 
theria introduces  the  most  conspicuous  and  troublesome  cases, 
but  differs  from  the  other  forms  of  multiple  neuritis  in  the  order  in 
which  the  various  parts  become  affected.  Tuberculosis  pro- 
duces a  certain  number  of  cases  ;  so  do  typhoid  fever,  smallpox, 
chicken-pox,  and  especially  syphilis — but  the  latter  causes  obtain 
but  rarely  in  children.  Rheumatism  is  said  to  account  for  a  cer- 
tain number  of  instances  ;  certainly  in  this  disease  the  course  of 
the  nerve-trunks  is  frequently  tender  on  deep  pressure.  Expo- 
sure to  cold  is  an  occasional  cause,  and  excessive  cold  bathing 
has  been  known  to  produce  neuritis.  The  metallic  poisons  are 
powerful  factors  for  harm  of  this  sort.  Arsenic  has  caused  a 
number  of  cases  which  have  been  carefully  recorded ;  so, 
indeed,  has  lead.  Mercury,  carbonic  oxid,  and  phosphorus 
have  in  rare  instances  produced  a  neuritis. 

Alcoholic  neuritis,  of  course,  is  not  a  common  form  occurring 
in  children  ;  nevertheless  among  depraved  families  the  use  of 
alcohol  is  more  encouraged  in  the  young  than  might  be  sup- 
posed, affecting  not  only  the  peripheral  nerves,  but  producing 
destructive  changes  in  the  liver,  kidneys,  and  brain.  Moreover, 
the  appetite  for  alcohol  in  children  is  sometimes  not  wanting. 
Alcoholism  and  tuberculosis  in  the  parents  are  said  to  be  pre- 
disposing factors.  Injuries  of  nerves  by  fracture,  wounds,  blows, 
and  direct  pressure  are  followed  occasionally  by  neuritis. 

Morbid  Anatomy. — In  neuritis  the  changes  are  chiefly 
interstitial  or  parenchymatous,  the  perineurium  usually  escaping, 
and  the  damage  is  confined  to  the  peripheral  nerves.  In  some 
instances  the  nerve  is  swollen,  infiltrated,  and  its  sheath  hyper- 
emic,  of  a  red  color,  and  covered  with  minute  hemorrhages. 
Sometimes  the  muscular  tissue  is  involved,  the  fibers  being 
smaller  and  paler,  the  changes  there  being  both  parenchymatous 
and  interstitial.  One  of  the  most  striking  peculiarities  of  the 
phenomena  of  multiple  neuritis  is  the  fact  that  the  toxins  select 
the  peripheral  nerves  and  allow  the  spinal  centers  to  escape. 

The  resistance  of  the  more  remote  nerve-fibers  appears  to  be 
lessened  the  further  away  they  are  from  the  mother  cell. 

Symptoms. — The  first  symptom  of  a  multiple  neuritis  re- 
sembles an  acute  infectious  disease.  There  are  usually  a  chill, 
pains  in  the  back  and  limbs  or  joints,  simulating  acute  rheu- 


NEURITIS.  503 

matism,  rapid  rise  of  temperature,  103°  to  104°  F.,  headache, 
loss  of  appetite,  coated  tongue,  constipation  ;  locally,  pain, 
numbness,  and  tenderness.  "  The  most  characteristic  feature 
of  multiple  neuritis  is  the  association  of  motor  paralysis  with 
sensory  paralysis — the  distribution  of  each  harmonizing  with  the 
other  and  showing  very  definite  anatomic  limits.  The  paralysis 
is  of  the  flaccid  order,  leading  at  an  early  date  to  atrophy  of  the 
muscles,  and  the  electric  conditions  are  so  altered  that  we  may 
find  almost  every  possible  form  of  the  reaction  of  degeneration, 
from  a  mere  loss  of  faradic  irritability  to  an  absolute  lack  of 
galvanic  response  on  the  part  of  the  nerves  and  muscles.  The 
distribution  of  the  paralysis  is,  as  a  rule,  entirely  symmetric,  and 
may  affect  either  the  upper  or  lower  or  all  four  extremities  ; 
it  may  involve  every  part  of  all  the  extremities,  and  is  the  one 
affection  which  perhaps  more  frequently  than  any  other  leads  to 
a  complete  paralysis  of  every  limb  of  the  body  "  (Sachs). 

The  characteristic  phenomena  of  the  disease  are  wrist-drop 
and  foot-drop,  due  to  the  greater  disturbance  of  the  extensor 
muscles.  Sensory  symptoms  accompany  the  paralysis,  and 
where  pain  continues  to  persist  in  the  muscles  and  along  the 
nerve  tracts,  the  diagnosis  points  more  to  multiple  neuritis  than 
to  a  central  trouble.  Absence  of  pain  does  not  impair  the 
diagnosis  of  multiple  neuritis — motor  and  sensory  paralysis  is 
more  slowly  developed  than  in  central  affections,  and  there  is 
more  likely  to  be  premonitory  paresthesia.  Sensory  impairment 
is  pretty  equally  distributed  ;  at  first  there  may  be  hyperesthesia. 
Later,  pain  may  continue,  and  finally  the  sense  of  pain  be  lost 
along  with  the  muscular  and  temperature  sense.  Tremor  and 
incoordination  are  frequently  associated  in  neuritis  with  the  loss 
of  sensation  and  power.  Station  may  be  imperfect,  the  sway 
excessive,  or  total  inability  to  stand  if  the  eyes  are  closed.  The 
reflexes  in  the  affected  limbs  are  diminished  or  absent,  especially 
the  knee-jerk.  The  parts  affected  first  are  the  ends  of  the 
extremities,  and  a  weakness  very  early  attacks  the  extensors  of 
the  toes,  making  it  difficult  for  the  patient  to  extend  the  foot  in 
walking.  The  muscles  supplied  by  the  anterior  tibial  nerves  are 
the  most  frequently  affected  in  multiple  neuritis,  as  well  as  in 
poliomyelitis,  and  in  the  arm  the  muscles  supplied  by  the 
musculospiral  nerve.  The  nerves  supplying  the  muscles  of  the 
trunk  are  very  rarely  affected.  The  sensory  changes  are  about 
equally  distributed.  Pain  and  paralysis  are  the  distinguishing 
symptoms  of  multiple  neuritis,  but  occasionally  the  one  or  the 
other  is  absent,  or,  in  the  case  of  pain,  may  have  been  transient. 
Electric  reactions  are  extremely  varied,  both  in  character  and 


564  DISEASES    OF    THE    NERVOUS    SYSTEM. 

degree.  An  important  point  is  the  early  atrophy,  also  the 
absence  of  disturbances  of  the  bladder  and  rectum.  Glossy 
skin  and  edema,  common  in  diseases  of  the  peripheral  nerves,  are 
present  in  many  cases,  and  the  peculiar  tapering  of  the  fingers. 
The  course  of  multiple  neuritis  varies  with  the  intensity  of  the 
cause,  the  symptoms,  as  a  rule,  increasing  during  the  first  five  or 
six  weeks,  then  diminishing.  Both  sensory  and  motor  symptoms 
increase  together,  and  then  the  sensory  symptoms  rapidly 
lessen,  the  motor  phenomena  more  slowly ;  this  last  is  due 
to  the  atrophy  of  the  muscles  and  consequent  contractures. 
As  the  severity  of  the  symptoms  subsides,  even  in  the  worst 
cases,  recovery  is  usually  steady  and  complete. 

Diagnosis. — The  characteristic  feature  of  disease  of  the  per- 
ipheral nerves  is  the  close  association  of  sensory  with  motor 
phenomena,  indicating  an  involvement  of  the  same  nerve  areas. 
Also  there  are  usually  not  only  subjective  sensations  of  pain, 
but  tenderness  along  the  affected  nerve  tracts.  In  poliomyelitis 
the  onset  and  course  are  more  abrupt  and  violent,  and  the  cen- 
tral nervous  system  shows  wider  evidence  of  disease,  and  the 
paralyses  are  likely  to  be  more  one-sided  ;  in  neuritis,  more 
symmetric.  In  poliomyelitis  there  is  rarely  much  tenderness 
along  the  nerve  tracts  ;  as  a  rule,  the  pains  are  vague,  but  liable 
to  be  very  severe  in  the  early  course  of  the  disease.  The  elec- 
tric reactions  are  very  similar.  Moreover,  the  two  disorders 
may  coexist.  At  all  times  the  differential  diagnosis  between 
these  two  is  difficult.  The  most  important  point  is  to  recognize 
the  special  cause  of  the  neuritis.  Landry's  paralysis  begins  in 
the  legs,  first  one,  than  the  other,  then  spreading  to  the  upper 
extremities.  In  America,  Sachs  tells  us,  the  most  frequent 
cause  will  be  found  in  a  preceding  acute  infection — either  by 
poisoning  or  by  the  toxic  principles  produced  in  the  acute  infec- 
tious fevers  ;  next  in  frequency  is  malaria,  and,  lastly,  tubercular, 
syphilitic,  alcoholic,  metallic,  or  other  poisoning. 

Treatment. — The  treatment  of  multiple  neuritis  consists 
primarily  of  rest  in  bed  and  the  removal  or  limitation  of  the 
cause,  which  is  usually  a  definite  one — septic,  metallic,  or  mala- 
rial. During  the  height  of  the  malady  the  sensory  symptoms, 
particularly  pain,  require  alleviation,  and  for  this  heat  or  alternate 
heat  and  cold  are  best.  Next  comes  the  upbuilding  of  the  general 
health  by  general  hygienic  and  tonic  measures,  and  finally  the 
repair  of  the  paralyzed  nerve  and  muscle.  Warm  baths,  sys- 
tematically and  frequently  given,  are  useful  in  most  cases  to 
produce  a  variety  of  results — relief  of  painfulness  and  restlessness, 
stimulating  or  tranquiUzing  effects  upon  the  circulation,  and  aid- 


NEURITIS.  565 

ing  in  securing  sleep.  If  the  pain  is  excessive,  small  doses  of 
analgesics  are  suitable,  of  which  the  best  is  opium  or  the  coal-tar 
preparations,  used  with  caution  ;  the  salicylates  are  not  particu- 
larly useful  ;  chloral  or  strontium  bromid  by  the  rectum  is  some- 
times of  value.  Where  the  nerve  sheath  is  involved,  mercurial 
inunctions  have  been  used  with  success,  either  the  unguentum 
hydrargyrum  or  a  5  to  1 5  per  cent,  ointment  of  the  oleate  of 
mercury.  Arsenic  is  positively  dangerous.  In  the  majority  of 
cases  general  tonic  remedies  will  be  sufficient — cod-liver  oil, 
quinin,  and  strychnin.  In  the  malarial  form  quinin  is  necessary 
as  a  specific,  with  perhaps  minute  doses  of  calomel  to  aid  its  ac- 
tion. When  the  paralytic  symptoms  appear,  the  galvanic  current 
is  useful  both  as  a  sedative  and  tonic  ;  when  the  faradic  current 
produces  contractions,  it  is  useful  as  a  muscle  stimulant,  but  is 
not  to  be  used  where  there  is  hyperesthesia.  Contractures  may 
be  overcome  by  gentle  massage,  later  by  forcible  overextension. 
If  these  deformities  are  permanent,  tenotomies  and  orthopedic 
apparatus  are  indicated. 

Potassium  iodid  is  of  service  as  an  eliminant  where  much  peri- 
neural  exudate  exists. 

DIPHTHERIC  PARALYSIS. 

Paralysis,  more  or  less  severe,  follows  a  large  proportion  of 
cases  of  diphtheria,  and  bears  no  relation  to  the  severity  of  the 
attack  nor  to  the  previous  health  of  the  patient,  and  may  occur 
within  the  first  week  or  not  until  several  weeks  have  elapsed. 
Diphtheric  palsy  generally  follows  a  particular  order  ;  the  palate 
is  usually  the  first  and  often  the  only  part  affected,  shown  by  the 
regurgitation  of  liquids  through  the  nose  and  a  nasal  articulation. 
If  this  extends,  the  upper  and  lower  extremities  may  be  affected, 
at  first  as  a  mere  weakness  and  later  as  a  complete  paresis,  and  is 
generally  accompanied  by  marked  disturbances  of  sensation.  The 
sixth  nerve  is  often  affected,  supplying  the  external  rectus  muscle. 
Complete  oculomotor  palsy  is  rare,  but  ptosis  and  weakness  of 
one  or  more  muscles  supplied  by  the  third  nerve  are  often  seen. 
The  pupillary  reaction  is  often  sluggish,  with  impairment  of  ac- 
commodation. The  epiglottis  is  sometimes  paralyzed,  and  is  a 
source  of  distinct  peril.  The  reflexes  are  generally  diminished 
or  lost,  even  in  some  instances  where  there  is  no  actual  paralysis. 
Cardiac  failure  following  upon  diphtheria,  especially  where  there 
are  irregularities  of  respiration,  is  probably  due  to  loss  of  func- 
tion of  the  vagus. 

The  prognosis  is  distinctly  favorable,  though  the  course  may 
be  most  protracted.  Where  a  single  nerve  is  affected,  the  recoveiy 


566  DISEASES    OF    THE    NERVOUS    SYSTEM. 

is  more  prompt.  Hysteric  palsies  may  be  superadded  to  the 
original  lesion,  and  this  possibility  must  be  carefully  considered 
where  the  case  is  long  in  recovering.  A  return  of  reflexes  and 
electric  reactions  points  clearly  to  repair  of  the  nerve,  although 
the  muscle  atrophy  may  prove  troublesome. 

The  treatment  consists  of  general  measures  directed  to  the 
repair  and  maintenance  of  strength.  Feeding  should  be  particu- 
larly insisted  upon,  and  where  the  palate  is  paralyzed,  solids  are 
more  easily  swallowed  than  liquids.  If  the  difficulties  of  deglu- 
tition are  extreme,  the  nasal  tube  should  be  used,  or  rectal  feed- 
ing may  be  necessary.  Upon  the  slightest  suspicion  of  heart 
weakness  cardiac  tonics  should  be  given — digitalis,  strychnin, 
caffein,  and  hot  drinks.  For  respiratory  weakness  direct  excita- 
tion of  the  phrenic  nerves  by  slowly  interrupted  faradic  currents 
will  give  good  results. 

LEAD  PARALYSIS 

Occasionally  occurs  in  children,  as  has  been  proved  by  the 
researches  of  Putnam,  D.  D.  Stewart,  Jeffries  Turner,  and  others. 
It  may  be  most  important,  and  should  not  be  overlooked.  It 
usually  occurs  in  the  extensor  group  of  muscles  o'f  the  forearm 
and  legs,  producing  wrist-drop  and  foot-drop.  There  are  usu- 
ally along  with  this  marked  cachexia,  pallid  skin,  severe  head- 
aches, and  digestive  disturbances.  The  prognosis  is  favorable  for 
the  paralysis,  but  danger  exists  from  profound  nutritional  dis- 
turbances and  the  effect  of  the  poison  upon  the  brain. 

The  lead  is  only  occasionally  found  in  the  urine,  and  in  minute 
proportions  when  present,  confirming  diagnosis,  but  when  absent 
not  excluding  suspicion.  A  well-marked  blue  line  is  only  rarely 
seen,  and  chiefly  when  the  teeth  are  foul,  collecting  in  the  sulci 
between  them  and  the  gum.  It  consists  of  a  deposit  of  sulphid 
of  lead,  and  forms  inside  the  gum  at  its  extreme  edge,  and  only 
opposite  certain  teeth. 

The  discoloration  commences  as  minute  blackish  dots,  in  many 
cases  only  distinguishable  by  the  aid  of  a  lens.  The  absence 
of  these  appearances  does  not  negative  the  suspicion,  and  the 
diagnosis  must  rest  on  clinical  symptoms.  These  are:  (i) 
Paralysis ;  (2)  colic  and  muscular  pains  ;  (3)  convulsions ;  (4) 
ocular  neuritis  ;  (5)  spurious  meningitis  (Jeffries  Turner). 

/.  Paralyses. — The  first  paralytic  symptom  is  dropping  of  the 
toes  in  walking,  the  child  adopting  a  high  stepping  gait  to  raise  its 
toes  from  the  ground.  All  paralyses  are  bilateral.  If  the  disa- 
bility is  of  long  standing,  there  may  be  secondary  contractures, 
producing  a  talipes  equinus.  The  arms  are  not  so  frequently 


TETANUS.  567 

affected  as  the  legs,  and  usually  secondarily.  The  foot-drop  is 
first  to  occur  and  last  to  recover,  when  both  it  and  wrist-drop 
occur. 

2.  Colic  and  Muscular  Pains. — Colic  is  not  rare.  Constipa- 
tion is  usually  present  ;  vomiting  occasionally.  The  digestive 
disturbances  are  cyclic,  forming  "  bilious  attacks,"  and  occur  once 
in  a  month  or  .six  weeks.  Pains  in  the  legs  are  frequently  pres- 
ent and  are  characteristic.  When  severe,  the  pains  are  in  the 
nature  of  cramps. 

j.  Convulsions. — The  eclamptic  attacks  caused  by  lead  occur 
late  and  early  in  the  poisoning,  and  can  be  differentiated  from  those 
caused  by  other  conditions  only  by  collateral  testimony.  They 
are  severe  usually,  and  accompanied  by  cramps  in  the  abdomen 
and  legs. 

./.  Ocular  neuritis  occurs,  resembling  a  meningitis.  The  phe- 
nomena are  headache,  vomiting,  a  slight  squint,  depending  upon 
a  paresis  of  one  or  both  external  recti  muscles,  and  optic  neur- 
itis. In  such  a  grouping  the  suspicion  of  lead-poisoning, 
Turner  says,  is  most  grave.  Optic  atrophy  and  blindness  often 
result. 

Treatment  consists  of  general  measures  and  the  administra- 
tion of  iodids  in  moderate  doses,  besides  warm  baths  and  gentle 
massage. 

TETANUS. 
Synonym . — LOCKJAW. 

Tetanus  is  an  acute  infectious  disease  of  the  central  nervous 
system,  characterized  by  continuous  tonic  spasms,  with  marked 
exacerbations,  affecting,  as  a  rule,  the  muscles  of  the  jaw  and  the 
back  of  the  neck.  There  are  at  times  also  clonic  movements. 
There  is  much  ground  for  belief  that  the  primary  predisposing 
cause  of  the  trouble  is  always  an  injury,  through  which  the  bacilli 
of  tetanus  enter  and  infect ;  also  some  favoring  condition  of  the 
wound  or  some  concurrent  infection,  or  both. 

Causes. — The  direct  cause  of  tetanus  is  the  bacillus  of  Nico- 
laier,  a  slender  rod  with  rounded  ends.  Tetanus  occurs  about 
five  times  as  often  in  males  as  in  females,  a  fact  which  emphasizes 
the  necessity  of  a  traumatism  as  the  instrumental  cause.  It  oc- 
curs most  often  between  the  ages  of  ten  and  forty  years,  but  may 
arise  at  any  time  of  life.  The  tetanus  of  the  new-born  begins,  as 
a  rule,  between  the  fifth  and  tenth  day  after  birth,  thence  up  to 
twenty  days.  The  entrance  of  the  bacilli  here  is  by  way  of 
the  umbilical  cord,  and  it  must  be  admitted  as  possible  that 


568  DISEASES    OF    THE    NERVOUS    SYSTEM. 

other  toxic  agents  may  thus  irritate  the  nerves  of  a  newly  born 
child.  Colored  persons  are  more  subject  to  tetanus  than  white  ; 
the  filthy  much  more  than  the  clean,  everywhere.  Puerperal 
tenanus  is  rarely  seen  where  modern  surgical  principles  prevail, 
in  obstetric  as  well  as  in  surgical  practice.  The  feeble  are  no 
more  subject  to  tetanus  than  the  robust.  Tetanus  may  follow 
the  greatest  variety  of  injuries.  Punctured  and  contused  wounds 
of  the  hands  and  feet  are  supposed  to  be  most  liable  to  this  in- 
fection, but  it  may  follow  upon  many  minor  injuries.  It  is  more 
common  in  very  warm  than  in  temperate  climates. 

The  development  of  tetanus  requires  usually  a  few  hours,  but 
may  occur  at  once  after  an  injury  or  operation,  but  as  a  rule 
takes  from  one  to  two  weeks  and  may  take  four. 

Symptoms. — There  may  be  some  prodromes,  sometimes  a 
chill,  indistinct  pains  about  the  injured  part,  or  a  dull  headache  ; 
but  the  first  distinct  symptom  is  a  feeling  of  tightness  in  the 
jaws,  difficulty  in  mastication,  and  a  gradual  stiffening  of  the 
muscles  of  the  neck,  back,  and  lower  extremity,  until  opisthot- 
onos  is  produced,  or  of  the  jaws  until  these  are  firmly  clenched 
(trismus).  Later,  the  legs  become  rigid,  but  the  arms  escape, 
as  a  rule.  The  muscles  of  the  face  assume  a  characteristic  con- 
traction, especially  about  the  mouth,  giving  rise  to  a  sardonic 
grin  or  smile.  Now  and  then  the  attack  is  associated  with 
paralysis  of  the  facial  muscles.  Along  with  the  muscular  con- 
tractions is  pain.  The  contractions  of  the  thoracic  muscles  and 
the  diaphragm  may  imperil  life  by  interference  with  breathing. 
Swallowing  is  also  rendered  difficult,  and  the  muscular  pains 
grow  worse  and  worse  until  the  child  is  in  agony.  All  this  may 
cease  during  sleep,  but  on  the  instant  of  wakening  the  distress 
returns  with  full  force.  The  pulse  is  rapid  and  feeble,  possibly 
due  to  vasomotor  involvement.  The  temperature  varies  much  : 
in  some  instances  it  may  remain  normal  throughout,  in  others 
elevated  two  or  three  degrees.  Sometimes  it  runs  very  high,  to 
108°  or  110°  F.,  and  is  probably  then  due  to  an  intense  effect 
of  the  toxins  circulating  in  the  blood  upon  the  heat  centers. 
Thirst  is  often  great,  aggravated  by  the  profuse  perspiration  and 
the  difficulties  of  swallowing  water.  Urination  is  irregular,  and 
the  bowels  are  generally  constipated.  Death,  when  it  occurs, 
is  usually  from  failure  of  the  heart  or  asphyxia,  from  spasm  of 
the  glottis,  or  exhaustion  from  the  difficulties  of  swallowing 
food.  Most  cases  die  within  a  fortnight,  usually  in  four  or  five 
days.  If  the  patient  survives  the  first  two  weeks,  recovery  may 
be  looked  for.  In  tetanus  of  the  new-born  those  cases  in  which 
high  fever  occurs  seem  to  be  fatal. 


TETANUS.  569 

Pathology. — The  essential  pathology  of  tetanus  is  not  yet 
demonstrated  ;  in  fact,  no  characteristic  lesions  have  been  found 
either  in  cord  or  brain.  Rigor  mortis  sets  in  almost  at  once. 
Congestions  in  different  parts  and  granular  changes  in  the  nerve- 
cells  have  been  demonstrated.  The  cause  of  the  malady  is  the 
bacillus  of  Nicolaier,  which  is  found  in  the  soil  and  the  dust  of 
dwellings.  It  is  shaped  much  like  a  stumpy  pin,  and  is  capable 
of  resisting  great  heat  for  a  long  time.  These  bacilli  produce 
several  poisons,  tetanin,  tetanotoxin,  and  also  toxalbumins, 
which,  when  circulating  in  the  blood,  are  probably  the  cause  of 
the  disease.  Oxygen  is  destructive  to  these  bacilli,  which  helps 
to  explain  why  cleanliness  limits  their  action.  Bacteriologic 
researches  have  helped  enormously  to  explain  results  and  guide 
in  the  treatment.  Behring  and  Kitasato  have  demonstrated  the 
fact  that  the  blood-serum  of  tetanic  animals  produces  immunity 
in  others,  and  the  animals  thus  rendered  immune  have  powerful 
antitoxic  qualities,  producing  curative  effects. 

Diagnosis. — The  diagnosis  of  well -developed  cases  following 
external  injuries  is  easy.  Tetanus  may  be  mistaken  for  hydro- 
phobia, but  in  this  there  is  no  trismus  and  always  a  history  of 
dog-  or  other  animal-bite,  and  the  spasms  are  produced  only 
on  attempting  to  swallow.  From  tetany  a  diagnosis  may  be 
made  by  remembering  that  in  this  the  mode  of  onset  is  from  the 
periphery  inward,  and  also  through  Trousseau's  sign,  which  is 
that  in  tetany  a  spasm  may  be  brought  on  by  pressure  on  the 
large  nerve-trunks  and  arteries  of  the  extremities  affected,  and 
that  this  ceases  as  soon  as  the  pressure  is  removed.  Strychnin 
poisoning  also  resembles  tetanus,  but  never  begins  with  trismus. 
There  are  also  much  more  rapid  development  than  in  tetanus 
and  pains  in  the  stomach,  the  primal  rigidity  being  in  the  ex- 
tremities and  posterior  neck  muscles. 

Prognosis. — The  mortality  in  tetanus  is  85  per  cent,  in  trau- 
matic cases,  in  idiopathic  under  50  per  cent.  ;  a  favorable  symp- 
tom is  the  length  of  interval  between  the  injury  and  the  first 
spasms.  Much  hope  is  aroused  by  the  discoveries  of  Behring, 
in  the  matter  of  immunization,  which  may  in  time  control  the 
disease. 

Treatment. — The  treatment  of  tetanus  consists  in  prevention. 
Wounds  which  are  made  by  the  surgeon  are  under  absolute  con- 
trol and  should  not  be  a  source  of  infection.  Wounds  of  hands 
and  feet  incurred  by  accident  should  be  treated  aseptically  at 
once,  and  small  harm  will  follow.  If  tetanus  set  in,  general 
measures  must  be  instituted,  bearing  in  mind  the  exalted  state 
of  motility.  Quiet,  darkness,  and  isolation  should  be  secured. 


57O  DISEASES    OF    THE    NERVOUS    SYSTEM. 

All  moving  and  handling  and  feeling  the  patient  should  be  done 
gently  and  slowly.  If  the  jaws  are  locked,  a  wedge  may  force 
the  teeth  apart  to  introduce  food  by  tube  or  otherwise.  If  this 
fails,  the  tube  can  be  passed  through  the  nose,  or  rectal  feeding 
may  be  employed. 

To  limit  the  spasm,  chloroform  inhalations  are  very  useful,  also 
nitrite  of  amyl,  which  may  cause  the  spasms  to  be  greater  at  first 
but  lessened  afterward.  Chloral  hydrate  helps  to  produce  sleep, 
and  may  be  administered  by  the  mouth,  rectum,  or  hypodermi- 
cally  ;  five  to  fifteen  grains  may  be  given  at  once  and  repeated 
several  times  a  day.  Opium  and  morphin  are  also  most  helpful. 
Curare,  calabar  bean,  Indian  hemp,  belladonna,  and  other  drugs 
have  been  much  used  and  with  reported  good  results.  Warm 
baths  are  sometimes  of  use.  The  greatest  possibilities  exist  in 
the  injections  of  antitoxins  or  any  substances  which  may  here- 
after be  shown  to  possess  the  power  of  counteracting  the  poison 
in  the  human  system. 

The  action  of  the  antitoxic  serum  is  limited  :  it  can  not  directly 
act  on  the  tetanus  poison  and  destroy  it,  nor  undo  the  damage 
done  ;  it  can  only  prevent  further  damage  ;  moreover,  a  case  may 
go  on  to  fatal  termination  even  after  the  blood  has  been  rendered 
antitoxic  (Roux).  It  must  be  used  early  and  in  full  abundance 
to  be  of  value. 

In  diphtheria  the  position  and  character  of  the  lesion  are 
prompt  warnings,  but  the  poison  of  tetanus  is  insidious,  often 
causing  irreparable  damage  before  symptoms  show  clearly  (Lam- 
bert). Preventive  inoculations  are  most  effective,  and  should 
be  used  in  dirty  wounds  at  once,  when  and  where  tetanus  pre- 
vails (Bazy). 

To  sum  up,  use  local  disinfection,  physiologic  antidotes  to 
tranquilize  the  disturbed  spinal  cord,  and  give  antitoxic  serum ; 
limit  and  control  progressive  action  of  the  toxin. 

SIMPLE  CEREBRAL  MENINGITIS. 

Simple  cerebral  meningitis,  leptomeningitis,  or  purulent  men- 
ingitis is  an  inflammation  of  the  pia  mater  of  nontubercular 
origin. 

All  forms  of  meningitis  have  much  in  common,  and  the  de- 
scription of  any  one  is  much  the  same  for  all,  especially  the 
clinical  history  and  treatment,  which  will  be  considered  together. 
Cerebral  meningitis  may  be  divided  into  acute,  subacute,  and 
chronic. 

Causes. — Simple  meningitis  occurs  most  frequently  in  the  first 


SIMPLE    CEREBRAL    MENINGITIS.  5/1 

two  years  of  life,  then  rarely  until  after  fourteen,  and  between 
the  years  of  sixteen  and  forty-five  it  becomes  again  much  more 
common.  It  is  essentially  a  disease  of  childhood,  and  is  un- 
doubtedly more  common  than  we  have  evidence  to  prove. 

Exciting  causes  are  the  staphylococcus  and  streptococcus,  and 
other  micro-organisms  are  found  by  lumbar  puncture,  as  the 
pneumococcus.  The  predisposing  causes  are  injuries  to  the 
head,  extension  of  the  middle  ear  or  of  adjacent  inflammations, 
specific  diseases,  like  pneumonia,  scarlatina,  and  erysipelas,  pus- 
producing  organisms,  emboli,  and  thrombi.  Symptoms  simu- 
lating meningitis  often  occur  in  the  progress  of  acute  rheuma- 
tism, which  reveals  nothing  postmortem.  Trousseau  calls  these 
neuroses. 

Very  slight  traumata  are  many  times  the  probable  causes ; 
also  the  effect  of  intense  heat,  as  of  the  sun  ;  likewise  acute 
nephritis. 

Symptoms. — The  early  symptoms  are  very  obscure — a  mere 
indisposition  to  play,  a  slight  uncertainty  or  tottering  in  the  gait,  a 
tendency  to  sit  quiet,  with  some  nausea  and  vomiting.  All  these 
phenomena  may  pass  away  in  a  few  days,  or,  again,  the  vertigo 
may  increase,  the  headache  become  severe,  the  child  boring  its 
head  into  the  pillow,  swaying  it  from  side  to  side,  and  the  nausea 
and  vomiting  become  more  frequent.  The  ejections  are  of  the 
true  cerebral  type,  quite  causeless,  so  far  as  the  stomach  is  con- 
cerned, and  flung  straight  out  of  the  mouth — "projected."  If 
vomiting  occurs  independently  of  food  or  gastro-intestinal  changes 
and  associated  with  a  clean  tongue,  the  probability  of  its  being 
of  cerebral  origin  is  very  strong.  However,  there  may  well  be 
a  coating  of  the  tongue  (its  absence  does  not  forbid  the  suspicion 
of  cerebral  disease),  moderate  irregular  fever,  loss  of  appetite, 
constipation,  headache,  and  a  general  apathy — the  patient  is 
really  too  ill  to  complain.  Gradually  the  child  grows  more  list- 
less or  stuporous,  sleeping  much  and  crying  a  great  deal.  It 
may  become  fretful  and  restless  ;  convulsions  may  occur.  A 
common  feature  is  hyperesthesia,  especially  to  light  or  touch. 
Should  the  base  of  the  brain  be  also  involved,  the  symptoms  are 
identical  with  those  of  the  tubercular  form.*  If  the  patient  is 
firmly  grasped  or  roughly  handled,  it  winces  or  cries  out.  There 
is  intolerance  of  light  and  sound. 

The  temperature  runs  from  101°  to  104°  F.  ;  the  pulse  is  at 

*  We  know  of  a  child  at  the  Children's  Hospital  in  whom  photophobia  was  so 
severe  that  its  habitual  attitude  was  that  of  a  tripod  :  its  face  buried  in  the  pillow  and 
its  two  legs  well  apart  and  almost  straight.  It  finally  died  in  this  standing  position, 
and  remained  rigid  until  it  was  discovered  that  its  spirit  had  fled. 


5/2  DISEASES    OF    THE    NERVOUS    SYSTEM. 

first  rapid,  then  becomes  slow  and  irregular.  At  first  the  pupils 
are  contracted  and  subsequently  dilated  and  fixed.  The  neck 
and  limbs  usually  become  stiff.  After  a  time  the  apathy  deepens 
into  coma  ;  convulsions  occur  later.  The  deep  reflexes  are  gen- 
erally increased  ;  the  abdomen  becomes  retracted.  The  bowels 
are  generally  obstinately  constipated,  and  finally  the  stupor  is  so 
extreme  that  the  child  seems  all  but  dead — can  not  take  or  retain 
food,  and  yet  lives  on.  It  may  be  that  the  sphincters  are  early 
relaxed,  or  only  toward  the  end.  There  was,  for  a  long  time, 
much  importance  attached  to  a  local  vasomotor  palsy  following  a 
slight  scratch  on  the  skin,  called  the  "  tache  cerebrale,"  but  this 
has  little  significance.  All  these  symptoms  may  arise  in  about  a 
week  or  ten  days.  Paralyses  occur  in  some  cases,  very  like  those 
due  to  apoplexy,  or  may  be  local,  as  of  the  eye.  Sight  may  be 
lost  or  suspended.  If  the  case  tends  toward  recovery,  all  these 
symptoms  gradually  pass  away  ;  or  if  toward  death,  opisthotonos 
is  developed,  coma  deepens,  the  sight  goes,  respiration  becomes 
irregular,  usually  of  the  Cheyne-Stokes  type,  until  it  ceases.  At 
times  perfect  recovery  takes  place,  but  optic  atrophy  remains. 

Purulent  meningitis  is  associated  with  middle-ear  disease,  ne- 
crosis of  bone,  abscess,  septicemia,  and  frequently  cerebrospinal 
or  epidemic  meningitis.  Simple  or  plastic  meningitis  may  be 
connected  with  pneumonia,  rheumatism,  or  some  of  the  specific 
diseases. 

We  have  reported  elsewhere  the  case  of  a  little  girl  who,  when 
seven  weeks  old,  was  most  brutally  set  upon  by  an  older  child 
and  pounded  unmercifully  ;  thereupon  ensued  a  miserable  sickly 
state  for  several  months,  and  finally  there  occurred  an  attack  very 
like  acute  rheumatism,  but  which  proved  to  be  a  furious  condi- 
tion of  meningitis,  and  in  a  month's  time  she  got  well.  The  child 
has  been  under  our  observation  ever  since,  now  quite  ten  years, 
and  although  in  poor  circumstances,  living  mostly  in  unhygienic 
surroundings,  is  now  of  magnificent  physique  but  of  question- 
able mentality. 

Morbid  Anatomy. — In  simple  acute  meningitis  the  mem- 
branes are  opaque,  characterized  by  thickening  and  congestion 
with  infiltration  of  purulent  fluid.  The  inflammation  of  the  pia 
is  usually  accompanied  by  slight  involvement  of  the  dura  and 
the  substance  of  the  brain.  The  exudation  may  be  purulent  or 
nonpurulent ;  there  are  increase  of  the  cerebrospinal  fluid,  opacity 
of  the  arachnoid,  and  edema  of  the  brain  substance.  The  part 
most  extensively  diseased  is  the  pia  of  the  convexity,  that  of  the 
base  being  usually  free.  The  ventricles  are  overdistended  by 
fluid.  The  blood-vessels  of  the  pia  become  engorged  with 


SIMPLE    CEREBRAL    MENINGITIS.  5/3 

extravasation  of  leukocytes.      Postmortem  will  be  found  a  gluing 
together  of  the  pia  and  outer  layers  of  gray  matter. 

Meningitis  is  frequently  mistaken  for  typhoid  fever,  but  in  the 
earlier  stages  there  should  be  no  difficulty  in  differentiating  the 
two  diseases.  In  typhoid  fever  the  patient  is  dull,  apathetic, 
listless,  and  though  there  may  be  sensory  disturbances  and 
delirium,  yet  the  patient  is  not  especially  sensitive  to  external 
impressions  :  is  rather  apathetic.  In  meningitis,  and  especially 
in  meningitis  of  the  convexity,  among  the  early  symptoms  are 
marked  general  hyperalgesia  and  augmentation  of  all  the  re- 
flexes. The  patient  is  irritable  and  restless,  picks  at  his  nose 
and  lips,  throws  his  arms  about  in  an  aimless  manner,  perhaps 
gets  out  of  bed  without  knowing  why,  roams  about,  and  again 
returns  to  bed.  The  hyperesthesia  may  be  so  great  that  he  can 
not  bear  to  be  handled,  and  generally  there  is  intolerance  of 
light  and  sound.  Even  when  the  sufferer  is  lying  apparently  in 
a  stupor,  yet  the  smallest  disturbance  or  handling  may  cause 
him  to  scream  and  start. 

The  reflexes,  especially  the  knee-jerk  and  ankle-clonus,  are 
generally  exaggerated,  also  the  elbow-  and  wrist-jerks.  In  the 
later  stages  of  the  disease  if  effusion  has  taken  place  into  the 
ventricles  and  beneath  the  arachnoid,  these  signs  disappear. 
There  is  great  variability  in  the  condition  of  the  deep  reflexes, 
being  readily  elicited  one  day  and  not  to  be  found  on  the  next. 
In  typhoid  fever,  on  the  contrary,  they  are  only  increased  in 
severe  cases,  and  later  in  the  disease.  The  fever  of  meningitis  is 
fluctuating  and  runs  to  extremes  ;  that  of  typhoid  is  of  more 
regular  progression.  It  is  more  easily  controlled,  too.  Exam- 
inations of  the  blood  will  aid  in  the  diagnosis. 

Influenza  and  the  other  infectious  diseases  may  present  cerebral 
phenomena,  but  these  soon  pass  away  or  become  subordinate 
to  the  other  characteristic  symptoms. 

Diagnosis. — Certain  symptoms  are  common  to  all  forms  of 
meningitis ;  these  are  vomiting,  headache,  irregularity  of  the 
pulse,  unequal  pupils,  convulsions,  and  coma.  In  the  graver 
forms  of  meningitis  we  have,  in  addition,  high  fever,  evidences 
of  basilar  irritation,  progressive  emaciation,  and  a  rapid  increase 
of  all  the  symptoms.  To  distinguish  between  different  forms  of 
meningitis  is  always  difficult,  and  many  times  will  require  waiting 
for  later  developments,  which  may  be  recovery  or  death,  and  to 
be  confirmed,  if  possible,  by  autopsy.  Many  acute  infectious 
diseases  are  accompanied  by  pronounced  meningeal  symptoms, 
which  pass  away  with  the  severity  of  the  attack. 

Course  and  Prognosis. — A  case  of  simple  meningitis  con- 


574  DISEASES    OF   THE    NERVOUS    SYSTEM. 

tin ues  for  about  one  to  three  months.  Some  cases  recover — a 
veiy  few — and  remain  perfectly  well  ;  there  usually  follows 
serious  impairment  to  many  organs,  the  most  important  of  which 
is  the  brain.  Blindness  is  not  an  uncommon  result,  and  many 
deformities,  paralyses,  and  contractures  follow.  Where  the 
case  tends  toward  a  fatal  result,  the  symptoms  grow  steadily 
worse,  the  respiration  becomes  more  and  more  feeble,  and  death 
results  from  simple  exhaustion  or  some  complication,  such  as 
pneumonia. 

Treatment. — There  are  many  forms  of  meningitis,  and  the 
principles  of  treatment  are  the  same,  whether  these  be  due  to  a 
distinct  inflammation  of  the  meninges  or  mere  hyperemic  states 
which  arise  in  many  of  the  infectious  processes.  The  treatment 
as  given  here  is  suitable  for  all  these,  with  such  modifications  as 
may  be  necessary  for  special  causes.  First,  place  the  child  in 
bed  in  a  darkened  room  and  in  the  charge  of  a  thoroughly  compe- 
tent nurse.  The  bowels  should  be  emptied  promptly  ;  nothing 
is  better  for  this  than  calomel,  along  with  or  followed  by  a 
saline.  A  good  form  is  y1^  of  a  grain  of  calomel  with  two  grains 
of  Rochelle  salt  eveiy  half-hour.  Cold  is  useful  in  the  form  of 
ice-bags  to  the  head  or  neck,  but  must  be  sedulously  watched. 
Warmth  to  the  feet  is  comforting  and  of  value.  If  the  tempera- 
ture runs  high,  a  warm  bath, — 85°  to  95°  F., — gradually  cooled, 
may  be  cautiously  given.  Bromids  should  be  used  from  the 
beginning  if  the  stomach  will  endure  them,  if  not,  codein  ;  or  if 
convulsions  or  restlessness  are  severe,  chloral,  two  to  five  grains, 
by  the  rectum.  The  calomel  may  be  continued  in  smaller  doses, 
or  by  inunctions  of  mercury — 10  per  cent,  of  the  oleate  or  the 
unguentum  hydrargyri.  If  the  stomach  retains  well,  the  pro- 
tiodid  of  mercury  may  be  given,  or  the  bichlorid  with  iodid  of 
potassium,  continued  for  some  time. 

In  the  more  subacute  or  chronic  cases  shaving  the  head  and 
repeated  blisters  applied  to  the  scalp  are  of  great  service  to 
relieve  pain  and  for  their  sorbefacient  effect. 

SIMPLE  POSTERIOR  BASIC  MENINGITIS. 

There  is  recognized  a  simple,  nontubercular  form  of  meningitis 
occurring  mostly  within  the  first  year  of  life,  affecting  especially 
the  posterior  portion  of  the  base  of  the  brain  and  spinal  cord. 
The  cases  may  be  divided  into  three  groups:  (i)  Those  fatal 
within  six  weeks,  during  the  acute  stage  ;  (2)  those  fatal  at  the 
end  of  three  or  four  months  ;  (3)  those  which  recover.  Corre- 
sponding to  these  variations  in  the  duration  of  the  disease  are 


TUBERCULAR    MENINGITIS.  575 

differences  in  the  pathologic  appearance  in  the  groups  I  and  2. 
In  I  there  is  found  much  lymph  over  the  base  of  the  brain 
and  spinal  cord  ;  in  2  there  may  be  no  trace  of  lymph,  only 
thickening  and  opacity  of  the  pia  arachnoid,  with  adhesions, 
especially  between  the  medulla  and  cerebellum.  It  is  an  inter- 
esting point  that  in  the  rest  of  the  viscera  or  body  no  lesion  is 
found  except  such  accidental  complications  as  occur  in  any  pro- 
longed disease  during  the  last  few  days  or  hours  of  life.  The 
cause  of  this  is  assumed  to  be  a  specific  micro-organism  (diplo- 
coccus),  which  is  almost  identical  with  that  of  cerebrospinal  fever. 

TUBERCULAR   MENINGITIS. 

Tubercular  meningitis,  also  called  basilar  meningitis,  is  a  local 
manifestation  of  tuberculosis,  usually  at  the  base  of  the  brain, 
characterized  by  marked  cerebral  symptoms  due  to  deposits  of 
tubercles  in  the  pia  mater ;  and,  since  there  is  usually  effusion  of 
fluid  into  the  ventricles,  it  is  also  called  acute  hydrocephalus. 

In  many  instances  the  symptoms  may  be  divided  into  three 
stages  :  the  first,  of  hyperemia  and  irritation  of  the  pia ;  second, 
transudation,  pressure,  and  local  anemia  ;  third,  an  overwhelming 
of  the  integrity  of  the  centers.  Children  of  tubercular  predis- 
position, or  who  may  be  subject  to  the  infection  of  tubercu- 
losis, are  liable  to  this  form  of  meningitis.  Therefore,  it  is 
important  to  note  the  earliest  symptoms  of  onset,  which,  if  proper 
measures  are  then  used,  might  possibly  result  in  cure,  although 
it  is  doubtful  if  a  true  case  of  tubercular  meningitis  ever  got  well. 

Causes. — A  hereditary  predisposition  to  tuberculosis  is  the 
usual  origin.  Tubercular  infection  is  the  direct  cause,  and  this 
.  may  come  from  other  deposits  in  the  same  individual.  In  chil- 
dren the  disease  is  often  apparently  primary. 

Tubercular  degeneration  of  bronchial  glands,  which,  breaking 
down,  allow  the  poison  to  be  carried  into  the  circulation,  has 
been  pointed  out  as  a  potent  factor  in  causation.  The  direct 
cause  is  always  the  invasion  of  a  poison,  which,  according  to  our 
present  knowledge,  is  recognized  to  be  the  tubercle  bacillus 
which  spreads  along  the  lymph-channels,  exciting  inflammation. 
The  chief  danger  lies  in  an  unusual  vulnerability,  probably  con- 
genital, on  the  part  of  the  tissues.  Abundant  opportunity  for 
infection  comes  also  from  without,  through  various  articles  of 
food,  breast  milk  or  cow's  milk,  and  by  inhalation.  Bad  hygienic 
surroundings  favor  its  development.  (See  Tuberculosis.)  Most 
cases  occur  between  the  second  and  seventh  years. 

Symptoms. — The  onset  of  tubercular  meningitis  is  insidious, 


576  DISEASES    OF    THE    NERVOUS    SYSTEM. 

with  certain  prodromal  symptoms  :  the  child  becomes  listless, 
dull,  and  ceases  to  play  ;  when  disturbed,  it  becomes  irritable  and 
exhibits  various  gastric  disturbances,  especially  nausea,  and  per- 
haps for  a  week  things  remain  much  the  same.  Sleep  is  some- 
what disturbed.  If  these  symptoms  fail  to  disappear,  the  vomit- 
ing becoming  more  frequent  and  causeless,  the  headache  more 
intense  and  persistent,  associated  with  fever,  coated  tongue,  loss 
of  appetite,  constipated  bowels,  the  occasional  occurrence  of  the 
distressing  hydrocephalic  cry  (a  shrill  scream  caused  by  intense 
headache);  then  our  fears  becomes  graver.  If  there  is  then 
observed  slight  stiffening  of  the  neck,  a  slowing  of  the  pulse,  and 
increasing  prostration,  painfulness  on  every  passive  movement, 
unequal  pupils,  reacting  slowly  to  light,  diminished  conjunctiva! 
reflex,  with  clouding  of  the  cornea,  convulsive  seizures  of  the 
Jacksonian  type,  there  is  little  room  for  doubt.  Attempts  at 
swallowing  may  be  accompanied  by  slight  trismus.  Close 
examination  may  reveal  slight  palsies  of  some  branches  of  the 
facial  nerve  of  one  or  both  sides.  The  fundus  of  the  eye  dis- 
closes a  hyperemic  and  swollen  condition  of  the  papillae,  or  in 
some  instances  optic  neuritis.  Stiffness  of  the  muscles  of  the 
back  is  nearly  always  present,  amounting  sometimes  to  opis- 
thotonos.  Unilateral  or  bilateral  paralysis  of  branches  of  the 
facial  nerve  occurs,  and  other  changes  in  the  cranial  nerves, 
pointing  to  an  involvement  of  their  base.  The  "  tache  cerebrale  " 
is  easily  produced — a  common  feature  in  many  states  of  lessened 
vasomotor  tone.  The  extremities  may  be  palsied  more  or  less 
severely,  but  the  degree  of  this  is  most  difficult  to  learn,  volun- 
tary action  being  suspended  and  passive  movements  presented. 
The  surface  reflexes  become  diminished  or  lost,  but  the  deep  ones 
in  the  extremities  are,  as  a  rule,  exaggerated. 

The  belly  becomes  scaphoid,  convulsions  now  and  then  appear, 
general  in  character  but  not  to  the  extent  that  the  involvement 
of  the  pons  and  medulla  would  lead  one  to  suppose  ;  at  last  the 
paralysis  may  become  more  complete,  the  pupils  dilated,  and  the 
temperature  drop  to  95°  or  94°  F. 

The  position  of  the  child  in  bed  is  usually  on  one  side,  with 
limbs  drawn  up,  fingers  clenched  over  the  thumb,  head  strongly 
retracted.  Later  on  delirium  may  develop,  with  rapid  and  irreg- 
ular pulse  ;  the  temperature  falls ;  respiration  assumes  the 
Cheyne-Stokes  type.  The  duration  of  this  disease  is  from  three 
to  six  weeks.  In  some  cases  there  is  greater  or  less  degree  of 
paralysis,  due  to  pressure  of  the  excessive  exudate.  This  paral- 
ysis may  be  of  the  upper  or  lower  extremities. 

Cutaneous  reflexes  throughout  the  entire  body  are  lost.    Deep 


TUBERCULAR    MENINGITIS.  577 

reflexes,  as  a  rule,  are  increased.  It  needs  to  be  emphasized  that 
in  the  course  of  this  disease  there  are  periods  when  the  patient 
feels  much  improved  ;  this  inspires  false  hopes  in  the  parents. 
Often  both  physician  and  parents  are  deceived  in  this,  a  recrudes- 
cence occurring  later,  carrying  off  the  lingering  sufferer.  We 
have  a  case  in  mind  where  this  marked  evidence  of  vitality  lasted 
many  weeks,  with  transient  palsies,  before  final  dissolution  came. 

Morbid  Anatomy  or  Pathology. — There  is  singularly  little 
to  be  seen  in  the  macroscopic  postmortem  appearances  of  the 
brain  in  cases  of  tubercular  meningitis.  At  the  base  evidences  of 
the  disease  are  usually  apparent :  the  pia  cloudy  and  protruding. 
Tubercles  are  most  liable  to  be  found  in  the  interpeduncular 
spaces  and  scattered  about  the  pia,  pons,  medulla,  and  spinal 
cord. 

There  may  be  no  tubercles  seen  and  almost  no  signs  of  inflam- 
matory process.  But  in  well-developed  and  severe  cases  the 
presence  of  small,  yellowish  nodules  along  the  blood-vessels  of 
the  Sylvian  fissure  are  noticed.  The  disorder,  however,  belongs 
to  the  infectious  processes  and  is  a  part  of  a  general  tubercular 
infection.  There  is  increase  of  fluid  in  the  ventricles.  The 
ependyma  is  edematous  and  soft.  Death  is  due  in  great  measure 
to  the  systemic  effect  of  the  tubercular  poison  and  its  ravages 
in  other  organs. 

Diagnosis. — The  difficulties  of  differentiation  between  the 
tubercular  and  other  forms  of  meningitis  are  exceedingly  great. 
The  average  practitioner  should  not  allow  the  basilar  symptoms 
to  escape  him.  An  acute  ocular  palsy  or  beginning  optic  neuritis 
points  directly  toward  the  basilar  or  tubercular  form.  Symptoms 
pointing  toward  an  involvement  of  the  convexity,  such  as  the 
vomiting,  temperature  changes,  etc.,  occur  more  frequently  than 
in  the  other  forms. 

Course  and  Prognosis. — Tubercular  meningitis  lasts  from 
about  three  to  six  weeks.  Those  who  die  within  a  week  or  so 
exhibit  fewer  postmortem  changes,  and  death  is  probably  due 
to  a  general  toxemia.  The  prognosis  is  bad  enough,  but  must 
always  be  guarded,  because  the  diagnosis  is  often  impossible. 
We  have  seen  a  case  at  the  Orthopedic  Hospital,  of  gravest 
severity  and  apparently  tubercular  meningitis,  get  well,  except 
that  the  child  became  an  imbecile. 

Treatment. — No  care  must  be  omitted  in  the  endeavor  to 
mitigate  the  sufferings  or  conserve  every  possible  chance  for 
recovery  in  the  sufferers  from  tubercular  meningitis. 

The  first  thing  is  absolute  rest  in  a  quiet  and  darkened  room  ; 
next  is  a  thorough  calomel  purge  and  the  application  of  cold  to 
37 


5/8  DISEASES    OF    THE    NERVOUS    SYSTEM. 

the  back  of  the  neck  and  warmth  to  the  extremities,  if  these  seem 
to  relieve.  Whatever  makes  the  patient  irritable  or  disturbs  in 
any  way  had  best  be  abandoned.  Sleep  is  much  more  important 
than  food. 

The  heart  action  and  respiration  must  be  maintained  ;  for  this, 
digitalis  and  coffee  or  the  caffein  salts  are  of  value.  The  food 
should  not  be  given  too  often,  lest  the  stomachic  disturbance 
thus  likely  to  be  caused  does  more  harm  than  good.  Concen- 
trated animal  extracts,  home-made  beef-teas,  various  broths,  and 
peptonized  milk  are  all  easily  swallowed  and  should  be  given  in 
shorter  intervals  and  in  smaller  quantities  if  rejected,  but  ordi- 
narily two  hours'  interval  is  enough. 

The  iodid  of  potassium  has  been  recommended  for  tubercular 
meningitis,  and  when  used,  must  be  pushed  to  the  utmost.  In 
one  recorded  case  as  much  as  900  grains  were  given  each  day 
and  was  followed  by  recovery.  An  autopsy  three  years  after 
in  this  case  proved  that  the  child  had  suffered  from  tubercular 
meningitis. 

There  comes  a  time  when  it  may  be  more  merciful  to  parents, 
attendants,  and  also  to  the  child  to  regard  the  case  as  hopeless. 
Surgical  interference  has  been  attempted  and  the  patient  re- 
covered. Interference  with  the  knife  probably  acts  per  sc  or  by 
"changing  the  character  of  the  inflammation,"  as  is  evidenced 
by  notable  cures  not  uncommon  in  tubercular  peritonitis  or 
in  tubercular  joint-lesions.  When  there  is  marked  intracranial 
tension,  the  operation  of  lumbar  puncture  offers  a  perfectly  safe 
opportunity  for  relief  of  symptoms.  This  can  be  readily  per- 
formed by  any  one  who  will  learn  to  make  use  of  this  procedure. 
We  have  found  it  most  satisfactory  both  for  diagnosis  and  to 
afford  relief,  which  is  sometimes  permanent — at  least  for  the  more 
distressing  phenomena. 

INFANTILE  CEREBRAL  PALSIES. 

Cerebral  palsies  occur  in  children  in  four  forms  :  spastic 
hemiplegia,  diplegia,  paraplegia,  and  monoplegia.  The  onset 
of  these  is  in  three  periods  :  (i)  During  intra-uterine  growth  ; 
(2)  during  labor ;  (3)  after  birth.  They  occur  more  frequently 
in  the  earlier  years — up  to  ten,  mostly  before  three  ;  7  per  cent. 
are  congenital.  The  palsies  are  spastic  in  type  (tending  toward 
spasm),  and  may  be  of  one  side  (hemiplegia) ;  of  both  sides 
(diplegia) ;  of  one  half  of  the  body  below  a  certain  level  (para- 
plegia) ;  of  one  limb  (monoplegia)  ;  this  last  is  very  rare.  Cer- 
tain special  features  are  common  to  all  these  forms  of  palsy : 


INFANTILE    CEREBRAL    PALSIES.  579 

rigidity  of  the  muscles,  contractions  of  tendons,  and  exaggera- 
tion of  all  the  deep  reflexes.  Convulsions  and  coma  commonly 
precede  the  diseased  state.  Most  cases  of  diplegia  and  para- 
plegia are  congenital,  while  most  cases  of  hemiplegia  are  acquired 
after  birth  (Peterson). 

Causes. — Prenatal  cerebral  palsies  are  due  to  many  causes. 
Trauma  to  the  mother  during  gestation,  especially  septic  pro- 
cesses, and  such  as  powerfully  disturb  the  circulation  ;  the  toxins 
of  the  zymotic  fevers,  pneumonia,  anemic  states,  along  with  fre- 
quently degenerative  changes  in  the  blood-vessels,  are  the  com- 
mon causes. 

Convulsions  in  the  mother  often  result  in  retardation  of  fetal 
brain  development ;  so  do  psychic  and  emotional  shocks  and 
nervous  and  other  strains. 

The  chief  cause  of  paralysis  during  parturition  is  a  slow  labor, 
exercising  a  long-continued  compression  on  the  fetal  brain  and 
circulation,  producing  meningeal  hemorrhage  or  thrombosis. 
This  is  most  common  in  first-born  children.  The  use  of  instru- 
ments to  relieve  this  tardiness,  though  it  may  occasionally  work 
havoc,  yet  affords  rather  a  means  of  prevention  in  most  instances 
by  relieving  the  overprolonged,  intracerebral  blood  pressure. 
Mere  rigidities  are  the  result  of  surface  lesions  ;  the  more  pro- 
found the  palsy,  the  deeper  the  lesion. 

Acquired  paralyses  are  largely  due  to  the  acute  infectious  dis- 
eases. Whooping-cough  and  pneumonia,  by  repeated  and  severe 
acts  of  coughing,  superinduce  vascular  engorgement,  from  which 
may  result  escape  of  blood  and  cortical  damage. 

Traumata,  fright,  and  various  forms  of  convulsions  are  instru- 
mental factors  many  times,  especially  in  those  of  feeble  resistance 
and  neuropathic  predisposition. 

Symptoms  and  Description. — The  cortex  being  the  usual 
seat  of  lesion,  convulsions  and  coma  are  customary  symptoms  of 
onset.  After  a  difficult  or  prolonged  birth,  or  one  not  con- 
spicuously tedious,  there  may  soon  appear  in  the  baby  cyanosis, 
asphyxia,  or  convulsions.  The  infant  may  exhibit  none  of  these, 
but  only  extreme  feebleness.  If  cerebral  damage  has  occurred, 
however,  there  will  later  be  noted  imperfect  or  delayed  coordin- 
ations, awkwardnesses,  grimaces,  etc.,  some  of  which  will  pass 
away,  yet  much  will  remain  or  change  to  rigidities,  athetosis,  and 
the  like.  The  continuance  of  convulsions  constitutes  epilepsy,  a 
common  result  of  the  characteristic  lesions. 

The  paralysis  is  most  obvious  in  the  limbs,  taking  the  form 
of  hemiplegia  (of  one  side),  both  arm  and  leg  being  affected 
more  or  less ;  in  both  arms  and  both  legs  (double  hemiplegia  or 


580  DISEASES    OF    THE    NERVOUS    SYSTEM. 

diplegia) ;  in  both  legs  (paraplegia)  ;  or,  very  rarely,  in  one  limb 
only  (monoplegia). 

When  the  leg  and  arm  are  both  affected,  recovery  takes  place 
first  in  the  leg  and  later  in  the  arm,  but  this  result  is  seldom 
perfectly  attained.  In  a  few  instances  all  recognizable  palsy  dis- 
appears, leaving  other  phenomena  to  mark  the  central  damage. 
The  face  is  sometimes  involved,  commoner  in  the  diplegias  ;  one 
side  of  the  face  may  be  paretic  and  the  other  contracted. 

Speech  defects  remain  in  a  large  number  of  cases,  especially 
the  congenital  variety  and  earlier  palsies,  and  this  from  damage 
of  whichsoever  side.  Centers  for  articulate  speech  are  not  deter- 
mined in  the  left  side  very  early,  and  their  development  is  easily 
interfered  with. 

Exaggeration  of  the  deep  reflexes  on  the  injured  side  is  the 
rule,  though  in  a  small  proportion  of  cases  these  are  lessened 
or  normal.  Contracture  and  rigidity  mask  this  phenomenon  at 
times.  In  a  certain  few  cases  of  arrested  cerebral  development 
the  palsy  is  flaccid. 

In  our  experience  the  knee-jerk  and  arm-jerk  are  markedly 
increased,  as  a  rule,  and  ankle-clonus  and  ankle-jerk  are  gen- 
erally to  be  elicited  in  excess  (the  lesion  being  in'  the  first  divi- 
sion of  the  motor  tract). 

The  gait  is  characteristic,  consisting  of  a  springy  action  of  the 
leg,  which  is  dragged  forward  with  an  obvious  effort  and  planted 
with  a  jerk.  The  shoes  on  the  palsied  leg  show  evidences  of 
extra  wear.  The  arms  are  waved  about  and  extended  overmuch 
in  the  effort  to  balance  the  body,  which  shares  in  the  spasticity 
of  the  limbs,  especially  while  in  action,  one  voluntary  movement 
helping  to  reinforce  that  of  other  parts.  The  foot,  too,  comes  to 
earth  with  the  ball  or  toe  down,  and  the  sufferer  pitches  toward 
the  affected  side  and  then  places  the  sound  foot  less  in  advance 
than  the  other. 

In  diplegia  and  paraplegia  there  is  a  doubling  of  this  strained 
effortful  gait.  The  absence  of  one  sound  limb  to  support  the 
other,  with  the  consequent  loss  of  balance,  causes  each  leg  to 
describe  a  half  circle  or  more,  and  the  foot  to  cross  over  in  front 
of  the  other. 

In  one  typical  case  in  our  practice,  that  of  a  peculiarly  vigor- 
ous girl,  she  swings  along  with  fair  speed,  occupying  much  space 
laterally,  hands  extended  or  poised,  resembling  a  bundle  of  steel 
springs  vibrating,  and  is  merely  a  vivid  illustration  of  the  usual 
type  of  progression. 

Postparalytic  disturbances  of  motion  are  notable  features,  being 
more  common  in  the  child  (one-third  of  cases)  than  in  the 


INFANTILE    CEREBRAL    PALSIES.  581 

adult.  The  forms  most  common  are,  in  their  order  of  frequency, 
choreiform,  rhythmic,  and  associated  movements.  To  these  may 
be  added  the  contralateral  adductor  spasm,  which  one  of  us 
studied  carefully.* 

The  choreiform  movements,  described  first  by  Weir  Mitchell 
as  "  postparalytic  chorea,"  are  easily  and  frequently  mistaken  for 
chorea.  This  can  be  differentiated  by  the  exalted  state  of  the 
deep  reflexes,  contractures,  tremors,  etc.  These  hyperkinesias 
or  exaggerations  of  movement  may  follow  other  states  than  par- 
alysis, as  the  athetoid  movements  in  the  fourth  of  Freud's  di- 
plegic  types  (Mills).  The  atrophy  often  seen  is  not  a  true 
muscular  wasting  so  much  as  a  failure  to  develop  from  restricted 
activities. 

In  most  cerebral  palsies  there  is  more  or  less  obvious  asym- 
metry of  both  the  body  and  skull.  Along  with  deformities  of 
the  cranium  and  other  evidences  of  degeneracy,  the  most  distress- 
ing symptom  of  cerebral  atrophies  is  the  epilepsy  so  commonly 
present.  The  palsy  may  fade  away  and  leave  this  blight  for  life  ; 
which,  by  the  way,  it  aids  materially  in  shortening.  Idiocy  or 
imbecility  very  often  is  a  resulting  and  conspicuous  feature : 
often  in  diplegias  and  paraplegias,  there  being  here  a  double 
lesion  involving  larger  areas  of  brain  structure. 

Morbid  Anatomy. — In  the  case  of  cerebral  palsies  occurring 
before  birth  the  lesion  is  usually  a  wide-spread  meningeal  hemor- 
rhage involving  both  hemispheres.  This  may  merely  check 
development  or  produce  loss  of  tissue,  and  is  most  destructive  to 
functional  activity,  bodily  and  mental.  Death,  happily,  occurs 
often  at  once  or  very  early,  nor  do  the  sufferers  survive  long,  as 
a  rule. 

There  may  be  found  porencephalia  (limited  absence  of  brain 
tissue)  or  cysts,  confluence  of  fissures,  or  other  conspicuous  de- 
formities. In  addition  there  are  more  minute  changes,  such  as 
defective  development  of  the  cellular  elements  in  the  cortex  and 
pyramidal  cells,  constituting  cortical  agenesis.  Epilepsy  is  a  com- 
mon result,  while  imbecility  is  the  rule. 

Pathology. — The  resulting  lesions  of  acute  apoplexies  are 
not  so  clear,  but  consist  of  atrophies,  sclerosis,  and  other  changes 
due  to  hemorrhage,  also  embolism  and  thrombosis.  Fatty  de- 
generation of  the  blood-vessels  is  the  probable  explanation  of 
the  escape  of  blood  in  a  large  number  of  cases  ;  also  the  more 
delicate  and  vulnerable  condition  of  the  blood-vessels  in  the 
young.  Heart-lesions,  pneumonia,  and  other  infectious  diseases 

*"  Internal.  Med.  Magazine,"  June,  1895. 


582  DISEASES    OF    THE    NERVOUS    SYSTEM. 

predispose  to  embolism.  The  form  would  probably  be  softened 
and  hemorrhagic  areas,  with  ruptured  vessels,  leukocytes,  granu- 
lar cells,  and  neurogliar  proliferations  (Mills). 

Whatever  is  the  initial  lesion  of  an  acute  cerebral  palsy,  when 
the  patient  survives  secondary  changes  occur  concealing  the 
first  cause,  and  hence  arise  atrophies,  areas  of  softening,  sclerosis, 
and  the  like.  The  sclerosis  is  largely  responsible  for  the  imbe- 
cility and  epilepsy,  transverse  fibers  connecting  intimately  all  parts 
of  the  hemispheres. 

Summary  of  the  Effects  of  Cerebral  Palsies. — The  face 
is  occasionally  affected,  but  recovers  most  rapidly  and  com- 
pletely. Palsy  of  the  muscles  of  the  eye  now  and  then  persists, 
especially  strabismus.  Defective  speech  is  common  in  all  cases, 
due  to  a  variety  of  causes,  mechanical  as  well  as  intellectual. 
Aphasia  occurs  in  which  the  lesion  is  on  the  left  side  as  well  as 
on  the  right.  The  deep  reflexes  are  exaggerated,  especially  in 
the  paralyzed  limbs,  but  may  occur  in  both,  even  in  one-sided 
palsy.  In  5  per  cent,  these  may  be  normal,  lessened,  or  absent. 
Rigidity  in  the  limbs  may  mask  this,  especially  the  ankle-clonus 
or  triceps  jerk  ;  morbid  movements  are  exceedingly  common. 
"  Athetosis,"  or  restless  ataxia,  occurs  in  20  per  cent,  of  the 
cases.  There  are  frequently  also  associated  movements  and 
imitation,  by  the  hand  or  limb  not  in  use,  of  the  movement 
voluntarily  made  by  the  opposite  limb.  Choreiform  movements 
are  more  frequent  in  hemiplegias  and  rare  in  diplegia ;  other 
disturbances  of  movement  are  rhythmic  contractions,  tremors, 
tetanoid  states,  and  nystagmus.  Rigidity  and  contractures  are 
common  and  graphic  features  of  nearly  all  these  palsies  ;  hence 
they  are  liable  to  apply  to  the  orthopedic  surgeons  rather  than 
to  the  physician,  and  the  orthopedist  should  in  all  instances 
take  charge  of  these  cases  and  relieve  deformity  to  the  uttermost 
possibility.  The  adductor  spasm  of  the  thighs  induces  a  crossed- 
leg  progression  which  impedes  movement  very  much  ;  this  in 
most  instances  can  be  partly  relieved  by  tenotomy  and  over- 
stretching. Talipes  equinovarus  is  also  common  in  hemiplegics. 
It  is  customary  in  all  forms  of  cerebral  palsy  to  find  rigidity 
with  contracture,  but  occasionally  a  case  of  flaccid  paralysis  ap- 
pears, and  this  is  probably  the  result  of  an  arrested  development 
rather  than  of  a  degenerative  change.  There  is  much  less  trophic 
disturbance  than  in  spinal  palsy ;  nevertheless,  there  is  a  local- 
ized retardation  of  growth,  especially  in  the  cases  beginning 
early,  the  limbs  developing  in  fair  proportion,  but  much  more 
slowly,  failing  to  attain  the  full  size  and  vigor  of  the  opposite  limb. 
The  whole  organism  suffers  ;  full  stature  is  almost  never  attained. 


INFANTILE    CEREBRAL    PALSIES.  583 

Occasionally  there  is  seen  the  same  localized  blueness  and  cold- 
ness in  the  extremities  observed  in  spinal  palsy.  Spinal  lesion 
may  coexist  with  the  cerebral.  Epilepsy  occurs  in  45  per  cent, 
of  all  cases  of  cerebral  palsy.  The  convulsions  are  usually  gen- 
eral, but  in  1 5  per  cent,  they  are  focal  or  Jacksonian.  It  is 
essential  always  in  examining  an  epileptic  to  search  for  evidences 
of  a  cerebral  palsy.  Feeble-mindedness,  imbecility,  and  idiocy  are 
also  often  met  in  direct  ratio  to  the  extent  of  the  pathologic  pro- 
cess ;  more  commonly  in  diplegias  and  paraplegias,  because  of 
the  larger  areas  of  brain  involved.  Mental  defects  are  rarer  in 
hemiplegics,  although  in  nearly  half  the  cases  of  cerebral  palsy 
of  whatsoever  degree  there  is  evidence  of  mental  deterioration. 
There  will  also  be  seen  the  various  stigmata  of  degeneration, 
cranial  deformities,  asymmetries,  Gothic  palate,  deformed  ears, 
hairiness,  etc. 

Prognosis. — It  is  far  from  unfortunate  that  children  marked 
from  the  beginning  rarely  survive  ;  those  who  do  are  liable  to 
develop  imbecility  as  well  as  epilepsy,  and  become  irretrievably 
lamed  or  stunted  in  mind  and  body.  No  opinion  can  be  formed 
as  to  the  degree  of  crippling  or  capacity  for  development  in  the 
congenital  forms  until  after  some  weeks  or  months  have  elapsed. 
In  the  double-sided  form  of  brain  palsy  mental  development  is 
most  likely  to  be  lacking.  So  long  as  contractures  remain  ab- 
sent we  may  hope  to  recover  a  fair  capacity  of  muscular  co- 
ordination. 

Differential  Diagnosis. — Infantile  cerebral  palsies  are  fre- 
quently confounded  with  acute  spinal  affections.  The  cerebral 
cases  are  characterized  by  spastic  rigidities,  contractures,  increase 
of  the  deep  reflexes,  normal  electric  reactions,  and  very  slight 
atrophic  changes.  The  forms  of  palsy  are  hemiplegia,  diplegia, 
and  paraplegia,  with,  very  rarely,  monoplegia ;  frequent  accom- 
paniments are  epilepsy,  imbecility,  and  morbid  movements.  Very 
rnild  cases  exhibit  almost  no  spasticity  or  contracture,  but  rather 
athetoid  or  choreic  movements  ;  the  spinal  and  the  cerebral  forms 
of  palsy  may  coexist  in  the  same  individual,  arising  at  different 
times,  and  such  a  complication  must  not  be  overlooked.  Cases 
of  persistent  chorea  should  be  most  thoroughly  searched  for  evi- 
dences of  hemiparesis  with  mental  defects  or  occasional  epileptic 
attacks,  which  often  are  obscure,  manifested  rather  by  mental 
states  than  disorders  of  motion. 

Treatment. — Recognizing  the  localized  form  of  the  lesion, 
along  with  the  triumphs  of  modern  surgery,  it  would  seem  a  most 
promising  possibility  to  take  away  a  well-defined  clot  and  thus 
remove  the  cause  of  the  trouble  ;  but,  alas  !  the  published  results 


584  DISEASES    OF   THE    NERVOUS    SYSTEM. 

of  operative  interference  in  cortical  hemorrhages  of  infants  and 
children  are  most  disappointing.  The  highest  authorities  agree 
that  the  best  treatment  for  infantile  apoplexies  is  almost  entirely 
expectant.  Absolute  quiet,  cold  to  the  head,  a  clearing-out  of 
the  bowels,  come  first ;  for  the  convulsions,  inhalations  of  chlor- 
oform, or,  better,  chloroform,  three  parts,  ether,  five  parts,  and 
nitrite  of  amyl,  one  part,  are  very  efficacious.  (See  Treatment 
of  Convulsions.)  After  a  few  days  begin  with  small  doses  of 
bromid  (and  add  to  this,  later,  an  iodid),  continuing  for  some  time. 
Keep  the  child  perfectly  quiet.  Feeding  should  be  of  the  sim- 
plest, and,  if  necessary,  by  the  rectum.  No  change  of  posture 
should  be  permitted  to  the  child  ;  all  shifting  of  garments  should 
be  made  by  the  nurse  and  with  the  utmost  care. 

Counterirritation,  mustard  baths,  and  the  like  are  merely 
offensive  meddling,  unless  there  is  marked  excitement,  when  if 
they  do  no  good,  they  may  do  little  harm.  Calomel  is  of 
value  to  secure  free  purgation.  The  bromids  and  chloral  are 
better  given  by  the  rectum.  Soon  the  parents  will  desire  treat- 
ment for  the  paralysis  and  other  symptoms,  and  this,  of  course, 
must  be  forthcoming  ;  but  they  must  have  the  nature  of  the 
lesion  explained,  making  it  clear  that  it  is  a  damage  wrought 
which  becomes  almost  at  once  a  chronic  disorder  and  not  an 
active  disease.  During  the  earlier  acute  processes  quiet  is  imper- 
ative, but  in  a  month  or  two  (judged  by  the  grade  of  recovery) 
the  paralyzed  limbs  may  receive  attention  in  the  way  of  bathings, 
massage,  and  electricity,  disturbing  the  brain  as  little  as  possible. 
The  form  of  electricity  to  be  chosen  is  mildly  increasing  faradism  ; 
galvanism  is  not  required  at  all.  The  electricity  serves  a  valuable 
purpose  in  enforcing  muscular  activities  which  are  beyond  voli- 
tional control.  The  degree  of  current  to  be  used  is  to  be  chosen 
empirically,  the  gage  of  which  is  a  moderately  full  reaction, 
compared  with  similar  healthy  muscles  in  the  same  child.  Our 
rule  is  to  produce  fifteen  or  twenty  good  strong  contractions  by 
means  of  the  slow,  interrupted  current,  to  be  followed  by  from 
three  to  five  minutes'  steady  application  of  the  rapid  interruption 
to  each  half  of  an  affected  limb.  This  is  quite  enough  daily  for 
a  month  ;  in  the  second  or  third  month  this  amount  may  be 
doubled  or  trebled  at  two  or  three  daily  sittings. 

Next  comes  massage,  which  must  be  given  with  the  greatest 
delicacy  ;  first  simple  centripetal  strokings  for  a  week  or  ten  days, 
then  cautiously  increased  gentle  frictions,  and,  by  the  end  of  a 
month  or  two,  deep,  thorough,  slow  muscle-kneading  and  rotation 
of  the  muscle  masses  may  be  given.  Of  extreme  importance  are 
extensions,  counterextensions,  and  rotations,  to  prevent  and  to 


TUMORS    OF    THE    BRAIN    AND    ITS    MENINGES.  585 

remedy  contractures.  Indeed,  there  is  no  one  agent  which  helps 
to  restore  a  paralyzed  limb  to  activity  so  powerfully  as  these 
overstretching  movements.  The  brain  centers  seem  to  be  thus 
stimulated.  Undoubtedly,  well-adjusted  apparatus  can  do  much. 
Once  the  contractures  have  been  thoroughly  formed,  the  ortho- 
pedic surgeon  must  be  consulted,  and  splendid  results  are  ob- 
tained at  his  hands. 

For  the  athetoid  choreic  movements  much  help  can  be  afforded 
by  fixed  dressings  and  other  forms  of  restraint. 

Far  and  away  the  most  important  duty  of  the  physician  is  to 
control  the  epilepsy.  This  is  due  to  secondary  changes  in  the 
brain,  the  outcome  of  the  original  lesion,  and  is  focal  in  character, 
although  not  always  strictly  Jacksonian.  Here  operative  inter- 
ference promises  great  things,  and  is  to  be  recommended  when 
fairly  indicated  by  a  clear  localization.  It  may  be  necessary  to 
continue  the  use  of  bromids  or  other  depressomotors.  Here  tri- 
onal  serves  a  good  purpose,  also  sulphonal,  antipyrin,  and  acetan- 
ilid,  as  described  at  length  under  Epilepsy. 

TUMORS  OF  THE  BRAIN  AND  ITS  MENINGES. 

New  growths  within  the  skull  in  childhood,  while  rare,  have 
of  late  been  studied  so  carefully  that  statistics  seem  to  show  them 
to  be  far  more  common  than  has  been  supposed.  Peterson  has 
collected  accounts  of  a  total  of  335.  The  largest  number  of 
these  are  due  to  tubercle.  Glioma  and  sarcoma  are  next  most 
common.  Cysts  are  comparatively  frequent,  resulting  usually 
from  some  preceding  morbid  process.  Carcinoma  and  gliosar- 
coma  follow  in  frequency.  The  site  of  the  tumor  is  most  often 
the  cerebellum — in  more  than  one-third  of  the  cases.  The  next 
most  common  situations  are  the  pons,  centrum  ovale,  basal  gan- 
glia and  lateral  ventricles,  corpora  quadrigemina,  and  crura  cere- 
bri.  Tumors  of  the  cortex  come  next,  and  the  other  situations, 
more  rarely  showing,  are  the  medulla,  fourth  ventricle,  and  base 
of  the  brain. 

Causes. — The  causes  of  brain-tumors  are  exceedingly  obscure. 
Certain  new  growths  arise  by  extension  from  deposits  of  a  similar 
nature  in  other  parts  of  the  body,  especially  tubercle  ;  this  is  also 
true  of  sarcoma  and  carcinoma.  Accidents  often  credited  with 
causal  agencies  are  of  doubtful  potentiality. 

Symptoms. — In  recording  those  symptoms  which  seem  to 
point  to  new  growth  in  the  brain  it  is  of  the  utmost  importance 
to  be  most  clear  and  exact  as  to  the  order  in  which  the  phenom- 
ena began,  for  upon  this  will  many  times  hang  the  possibility  of 


586  DISEASES    OF    THE    NERVOUS    SYSTEM. 

localization  or  an  estimate  of  the  extent  and  character  of  the 
growth.  It  is  also  necessary  to  record  almost  every  minute 
detail  of  history  with  elaborate  explanatory  phrases.  Thus, 
and  thus  only,  can  the  testimony  be  sifted  down  by  an  expert 
and  moderately  exact  knowledge  be  obtained.  The  possibilities 
for  help  are  small  enough,  but  such  as  exist  must  be  sought 
for  with  the  utmost  solicitude. 

The  symptoms  are  divided  by  Sachs  into  two  groups  :  the  first 
includes  the  general  symptoms  resulting  from  pressure,  and  the 
second  includes  those  due  entirely  to  the  location  of  the  tumor. 
Another  very  important  point  is  to  estimate  the  degree  of  rapidity 
by  which  the  tumor  grows,  for  even  the  most  delicate  structures 
will  slowly  adjust  themselves  to  pretty  extensive  pressure, 
whereas  a  rapidly  growing  neoplasm,  no  matter  how  small,  will 
markedly  derange  function.  The  vascular  supply  is  an  important 
factor  to  estimate,  and  the  disturbance  of  large  blood-vessels  is 
almost  as  grave  as  that  of  nerve  tracts.  The  symptoms  which 
point  to  a  new  growth  within  the  brain  are  headache,  nausea, 
vomiting,  insomnia,  convulsions,  and  double  optic  neuritis.  Head- 
ache in  children,  especially  very  young  ones,  is  often  not  clearly 
evidenced,  but,  nevertheless,  much  of  the  emaciation  and  weak- 
ness resulting  from  cerebral  tumors  is  due  to  the  persistent  in- 
somnia and  suffering  caused  by  headache.  The  character  of  the 
headache,  when  the  child  is  old  enough  to  describe  it,  is  intense, 
distressing,  deep-seated,  and  usually  referred  to  that  region  of  the 
•head  which  adjoins  the  new  growth.  When  along  with  this  there 
are  nausea  and  vomiting,  practically  causeless,  we  may  gravely 
suspect  an  intracranial  growth,  especially  where  these  continue 
for  a  considerable  length  of  time.  Vomiting  is  of  the  cerebral 
type,  coming  suddenly  at  almost  any  time,  often  as  a  complete 
surprise  to  the  child,  and  projectile — thrust  straight  out — or  in- 
duced by  the  slightest  disturbance.  There  is  also  occasional  or 
more  or  less  vertigo,  especially  associated  with  cerebral  tumors 
or  those  of  the  pons.  Convulsions,  too,  common  as  they  are  in 
children  and  due  to  slight  causes,  add  to  the  gravity  of  the  pic- 
ture if  associated  with  headache  and  vomiting,  and  especially  if 
all  these  are  repeated.  Localized  convulsions  may  point  to  an 
area  of  cortical  involvement.  Double  optic  neuritis,  due,  prob- 
ably, to  increase  of  intracranial  pressure,  if  along  with  continued 
headache  and  vomiting,  completes  the  clinical  picture  of  growth 
within  the  brain.  This  may  not  interfere  with  vision  and  hence 
may  not  be  suspected.  A  moderate  familiarity  with  an  ophthal- 
moscope is  usually  sufficient  to  investigate  so  conspicuous  a 
symptom.  We  were  able,  on  one  occasion,  to  thus  confirm  a 


-. 


TUMORS    OF    THE    BRAIN    AND    ITS    MENINGES.  587 

suspicion  of  cerebral  tumor  in  an  out-of-the-way  country  place 
with  an  ordinary  head  mirror  and  pocket  lens.  This  change  is 
usually  observable  in  both  eyes,  although  appearing  in  only  one 
for  a  long  time.  Along  with  these  conspicuous  general  symp- 
toms are  more  or  less  well-marked  disturbances  in  pulse-rate  and 
respiration.  The  localizing  symptoms  are  numerous,  but  are  not, 
as  a  rule,  capable  of  being  interpreted  by  the  general  practitioner, 
but  are  exceedingly  important  for  him  to  recognize,  enumerate,  and 
record.  The  first  of  these,  called  the  MacEwen  symptom,  is  per- 
cussion over  the  skull,  which  brings  out  local  tenderness  and 
increased  dullness.  This  is  not  always  significant  of  tumor,  but 
may  also  indicate  abscess  or  overdistended  ventricles.  Nor  is 
this  altogether  to  be  relied  upon,  even  by  the  most  skilful.  It  is 
best  elicited  by  auscultatory  percussion.  Following  these  indi- 
rect or  localizing  symptoms,  as  admirably  elaborated  by  Sachs, 
we  may  note  that  tumors  of  the  cortex  are  not  easy  to  differen- 
tiate from  those  of  the  subjacent  white  matter,  although  the  order 
of  development  will  aid  us.  Tumors  of  the  motor  area,  in  or  near 
the  gray  matter,  are  liable  to  give  rise  to  convulsive  seizures  from 
the  start,  whereas  those  beginning  in  the  underlying  white  matter 
are  more  likely  to  produce  gradually  appearing  paralytic  phe- 
nomena, and  subsequently  those  of  direct  cortical  irritation. 
Moreover,  the  meninges  lying  most  nearly  adjacent  to  the  cortex, 
disturbances  thereabout  are  more  liable  to  produce  intense  head- 
aches and  convulsions. 

Tumors  of  the  frontal  lobe  are  lacking  in  localizing  symptoms, 
except  such  as  have  to  do  with  producing  changes  in  character 
or  intelligence,  or,  if  low  down,  in  the  functions  of  the  olfactory 
bulb,  and  possibly  disturbances  in  salivation.  The  third  frontal 
convolution,  in  which  reside  the  motor  centers  of  the  speech 
function,  may  exhibit  motor  aphasia  or  agraphia.  If  along  with 
these  there  should  be  seen  localized  twitchings,  as  in  the  arm  or 
hand,  we  may  suspect  trouble  in  the  motor  areas  of  the  cortex 
or  lower  tracts.  Tumors  of  the  parietal  lobe  are  said  by  Dana 
to  be  followed  by  sensory  changes  in  the  limbs  of  the  opposite 
half  of  the  body ;  word-blindness  is  also  likely  to  accompany 
disturbance  of  the  parietal  lobule.  Disturbance  of  the  vision 
may  arise  from  pressure  in  this  locality,  although  the  chief  seat 
of  disturbances  of  sight  has  to  do  with  pressure  in  the  occipital 
lobe,  especially  the  cuneus.  The  temporosphenoid  lobe  contains 
the  centers  for  hearing  and  for  speech,  and  growths  in  this 
region  frequently  give  evidence  of  their  existence  by  impairment 
of  hearing  and  by  sensory  aphasia.  Tumors,  even  very  small 
ones,  in  the  line  of  the  great  motor  tracts,  in  the  basal  ganglia, 


588  DISEASES    OF    THE    NERVOUS    SYSTEM. 

especially  the  internal  capsule,  give  rise  to  a  wide  variety  of 
morbid  phenomena.  Tumors  of  the  crura  cerebri  are  to  be 
recognized  by  the  early  association  of  paralysis  of  both  motion 
and  sensation  in  the  opposite  half  of  the  body,  along  with 
oculomotor  symptoms,  ptosis,  paralysis  of  the  muscles  governing 
the  eyeballs,  the  iris,  and  the  ciliary  muscle.  The  close  juxta- 
position of  both  peduncles  may  give  rise  to  paralysis  of  both 
halves  of  the  body,  or  possibly  double  ptosis  or  double  oculo- 
motor symptoms.  Tumors  of  the  medulla  oblongata  produce 
symptoms  similar  to  those  met  with  in  bulbar  palsy,  as  well  as 
disturbances  of  the  centers  in  the  fourth  ventricle,  including 
disorders  of  deglutition,  in  respiration  and  the  cardiac  movements, 
and  with  increased  urination  or  glycosuria.  They  are  bilateral 
in  character,  owing  to  the  close  juxtaposition  of  the  two  halves 
of  the  brain  at  this  level.  They  also  involve  disturbances  of 
sensation  and  partial  or  complete  hemianesthesia.  Tumors  of 
the  cerebellum  produce,  in  addition  to  the  general  symptoms 
enumerated,  a  peculiar  and  extensive  vertigo  or  reeling  gait, 
known  as  cerebellar  titubation,  resembling  the  staggering  of  a 
drunken  man,  and  attributed  to  a  special  disturbance  of  the 
middle  peduncle.  Giddiness  is  a  much  more  constant  factor  in 
cerebellar  than  in  other  brain-tumors  ;  so  are  affections  of  the 
sixth  nerve,  with  a  resulting  paralysis  of  the  rectus  externus 
muscle.  The  seventh  and  eighth  nerves  are  also  frequently 
involved,  and  phenomena  due  to  this  will  aid  materially  in  con- 
firming the  diagnosis.  At  times  symptoms  of  cerebellar  tumor 
are  by  no  means  marked,  or  differ  but  little  from  those  in  other 
parts  of  the  brain.  Paralysis  of  one  or  both  sides  follows  upon 
an  extension  to  the  pons  and  oblongata  ;  the  reflexes  are  liable 
to  be  exaggerated,  but  may  be  diminished  or  lost. 

Diagnosis. — Brain-tumors  are  to  be  differentiated  from  chronic 
hydrocephalus,  meningitis,  abscess,  and  cerebral  hemorrhage. 
In  the  case  of  meningitis  this  should  not  be  'difficult  if  the  histoiy 
of  the  case  is  clearly  obtainable.  Solitary  tubercles,  producing 
more  or  less  mischief,  may  be  associated  with  meningitis  ;  the 
cranial  nerves  are  progressively  disturbed,  and  it  may  be  with 
relatively  slight  morbid  phenomena.  Abscess  generally  affords 
some  history  of  septic  process,  and  is  usually  accompanied  by 
fever  and  not  by  optic  neuritis. 

Treatment. — In  the  light  of  our  present  knowledge  very 
little  can  be  expected  in  the  way  of  treatment  for  tumors  of 
the  brain,  except  possibly  to  relieve  some  of  the  more  serious 
symptoms.  Postmortem  findings  show  that  even  with  moderately 
good  localization  the  tumors  are,  as  a  rule,  practically  inoperable. 


INFANTILE    SPINAL    PARALYSIS.  589 

Absorbents,  such  as  mercury  and  the  iodids,  are  of  more  or 
less  use  to  reduce  the  pressure  of  the  cerebrospinal  fluids,  and 
by  this  means  localized  headaches  and  nausea  may  be  mitigated. 
These  drugs  should  be  given  in  increasing  doses  to  the  verge  of 
toxic  endurance.  Headaches  are  relieved  by  the  coal-tar  anal- 
gesics and  opiates.  It  is  a  questionable  service  to  prolong  the 
life  of  such  sufferers  unduly,  and  yet  we  are  certainly  not  justi- 
fied in  withholding  any  reasonable  means  for  relieving  distress. 


ABSCESS  OF  THE  BRAIN. 

Abscesses  are  occasionally  found  in  the  brains  of  children, 
either  superficial  or  deep,  or  in  one  or  the  other  hemisphere,  and 
more  often  in  the  white  matter.  They  generally  arise  from 
suppurative  processes  in  the  middle  ear,  and  on  the  same  side 
as  that  of  the  affected  ear,  although  it  may  be  on  the  opposite. 
The  symptomatology  is  extremely  obscure.  The  search  for  a 
cerebral  abscess  is  a  most  uncertain  quest,  and  they  are  not 
seldom  demonstrated  post-mortem,  to  the  surprise  of  all  con- 
cerned. In  the  more  acute  conditions  we  have  the  ordinary 
symptoms  of  sepsis, — chilliness,  fever,  emaciation, — along  with 
the  symptoms  of  cerebral  tumor,  headache,  convulsions,  vomit- 
ing, giddiness,  together  with  local  tenderness  of  the  scalp  and 
occasionally  optic  neuritis.  The  temperature  may  be  subnormal ; 
there  may  be  paralysis,  which  is  apt  to  be  of  one  side. 

The  treatment  is  chiefly  prophylactic,  by  giving  especial  care 
to  the  prompt  and  thorough  treatment  of  ear  diseases.  Early 
operation  has  occasionally  brought  about  satisfactory  results, 
and  should  always  be  hopefully  considered,  although  little  has 
as  yet  been  done  to  justify  expectations  based  upon  these  views, 
which  are  in  the  main  theoretic. 


INFANTILE  SPINAL  PARALYSIS. 
Synonym. — POLIOMYELITIS  ANTERIOR  ACUTA. 

Acute  anterior  poliomyelitis,  myelitis  of  the  anterior  horns 
of  the  spinal  cord,  atrophic  spinal  paralysis,  infantile  or  the 
"essential"  paralyses  of  infancy,  etc.,  is  an  acute  febrile  disease 
of  probably  infectious  origin  and  rapid  development,  producing 
extensive  paralysis,  some  part  of  which  is  permanent,  followed 
by  muscular  atrophy,  imperfect  bone  development,  and  deformity. 

Causes. — The  majority  of  cases  occur  before  ten  years  of 
age  ;  three-fifths  before  four  years  ;  it  is  rare  before  six  months, 


590  DISEASES    OF    THE    NERVOUS    SYSTEM. 

but  in  the  second  six  months  susceptibility  is  greatest.  Heat  is 
shown  by  Sinkler  to  be  a  powerful  predisposing  factor  ;  four- 
fifths  of  the  cases  occur  in  summer,  mostly  in  July  and  August ; 
Sachs  asserts  that  75  per  cent,  arise  between  July  and  October. 
A  rapid  chill  of  body  has  also  been  shown  to  excite  the  onset  of 
the  disorder,  a  condition  which  may  occur  as  well  in  hot  as 
in  cold  weather.  Fever  of  various  kinds  are  often  blamed,  but 
the  diagnosis  of  the  symptomatic  initial  fever  can  seldom  be 
differentiated  from  those  ushering  in  the  infectious  or  other  in- 
flammatory processes.  Slight  injuries  are  reckoned  as  adequate 
causes  by  some,  but  all  such  histories  need  to  be  rigidly  sifted. 
A  specific  cause  of  microbic  kind  is  almost  certainly  behind  the 
accidental  ones. 

Poliomyelitis  represents  an  acute  inflammatory  process  of  the 
anterior  gray  matter  of  the  cord,  and  the  only  satisfactory  ex- 
planation of  this  is  to  assume  an  infection  which  tends  to  select 
a  location  in  the  cord. 

Pathology. — Poliomyelitis  is  admitted  to  be  an  acute  inflam- 
matory condition  of  the  anterior  gray  matter  of  the  spinal  cord. 
It  is  assumed,  on  good  grounds,  to  be  due  to  an  acute  infection 
which  shows  a  predilection  for  the  cells  of  the  spinal  cord,  just 
as  other  acute  infectious  diseases  choose  their  customary  sites. 
All  the  clinical  facts  point  to  a  microbic  cause,  but  this  is  not 
yet  proved,  although  the  fact  that  it  has  appeared  epidemically 
further  strengthens  the  assumption.  Of  late  the  theory  has  been 
advanced  that  the  micro-organism  gains  access  to  the  system 
through  the  gastric  mucosa. 

Goldscheider's  studies  lead  to  the  reasonable  conclusion  that 
a  condition  of  irritation  is  present  in  the  walls  of  the  blood- 
vessels of  the  cord,  leading  to  their  dilatation  and  to  the  pro- 
liferation of  their  endothelial  elements.  Later  degenerative 
changes  occur  in  the  ganglion  cells,  as  well  as  in  the  nerve-fibers 
appearing  in  the  vicinity  of  the  altered  blood-vessels. 

The  inflammatory  process  is  interstitial,  not  parenchymatous, 
and  may  be  limited  to  a  few  segments  of  the  cord,  or  extend 
to  the  medulla  and  pons.  The  muscles  become  atrophied, 
the  fibers  diminished  in  size,  possibly  disappearing,  their  places 
being  filled  by  adipose  tissue.  The  bones,  too,  become  smaller 
and  denser. 

Diagnosis. — Poliomyelitis  in  the  earlier  stages  may  be  readily 
confounded  with  acute  cerebral  disturbances,  as  meningitis  and 
apoplexy.  In  meningitis,  however,  there  are  vomiting,  rigidity 
of  the  neck,  headaches,  and  affections  of  the  cranial  nerves.  In 
poliomyelitis  these  do  not  appear,  and  convulsions  and  coma  are 


INFANTILE    SPINAL    PARALYSIS.  59! 

brief.  In  well-pronounced  acute  cerebral  palsy  the  differences 
are  clear,  but  if  less  marked,  difficulties  arise.  The  phenomena 
of  onset  are  much  alike,  but  the  clinical  features  are  in  strong 
contrast. 

ACUTE  SPINAL  PALSY.  ACUTE  CEREBRAL  PALSY. 

Onset    sudden,    with    fever,    coma,    and  Onset    sudden,    with    fever,    coma,    and 

convulsions.        Convulsions      rarely  convulsions.      Convulsions  apt  to  be 

repeated  after  first  few  days.  repeated. 

Paralysis  flaccid,  associated  with  atrophy.  Paralysis  spastic  ;  no  atrophy  ;  associated 

with  rigidity  and  contractures. 

Paralysis  widely  distributed,  possibly  in-  Paralysis    generally    hemiplegic,    some- 
volving  all  extremities,  or  narrowly  times  diplegic  or  paraplegic.   Mono- 
limited   to  one  member   or   even  a  plegia  rare, 
single  group  of  muscles. 

Electric  reactions  altered  (R.  D.).  Electric  reaction  normal. 

Deep  reflexes  diminished  or  lost.  Deep  reflexes  exaggerated. 

Intellect   never    permanently   involved ;  Intellect   often   involved  ;    epilepsy   fre- 

no  epilepsy.  quent. — (From  Sac/is.) 

Between  poliomyelitis  and  peripheral  (multiple  or  simple) 
neuritis  the  diagnosis  is  often  difficult.  In  both  the  onset  may 
be  sudden,  but  it  is  more  slow  in  neuritis,  as  a  rule. 

There  is  less  evidence  of  general  nervous  disturbance  in  neur- 
itis usually,  but  where  this  is  the  result  of  a  distinct  toxin,  the 
poison  may  produce  cerebral  phenomena  very  like  those  symp- 
toms in  the  early  stages  of  poliomyelitis. 

Pain  along  nerve-trunks  is  more  pronounced  in  neuritis  and 
of  longer  duration  ;  but  the  degrees  of  this  are  hard  to  deter- 
mine in  children.  Atrophies,  electric  reaction,  and  reflexes 
may  be  the  same  in  both.  Muscular  dystrophies  may  be  mis- 
taken for  poliomyelitis  and  it  for  them,  especially  the  peroneal 
form  of  progressive  muscular  atrophy  (Charcot-Marie  type). 
Atrophies  are  more  progressive,  are  bilateral,  slow  to  progress, 
do  not  retrogress,  and  have  incomplete  electric  reaction. 

Symptoms. — Acute  poliomyelitis  comes  on  suddenly  without 
distinct  prodromes,  much  in  the  manner  of  onset  common  to  the 
acute  infectious  diseases,  with  fever,  vomiting,  sometimes  con- 
vulsions, and,  rarely,  coma.  All  these  may  be  so  slight  as  to 
escape  notice  until  the  motor  disabilities  are  manifest.  These 
symptoms  last  a  few  hours  or  days  and  gradually  subside,  leav- 
ing the  paralysis.  There  is  often  tenderness  along  the  affected 
nerves.  The  palsy  is  of  the  flaccid  kind,  like  all  those  depend- 
ing upon  lesions  of  the  second  division  of  the  motor  tract,  and 
includes  the  ganglion  cells  in  the  anterior  horns,  the  anterior 
nerve-roots,  peripheral  nerves,  and  the  muscle.  This  is  associated 
with  atrophy  in  the  affected  parts.  The  electric  reactions  are 
altered  almost  from  the  first.  The  reflexes  are  diminished  or 


592  DISEASES    OF    THE    NERVOUS    SYSTEM. 

lost.  .The  fever  is  seldom  above  103°  F.,  and  more  often  is 
very  slight.  It  lasts  for  a  day  or  two,  but  in  severe  cases  of 
this  disease  may  continue  with  variations  several  days.  Vomit- 
ing is  quite  a  constant  feature,  occurs  early,  and  is  independent 
of  gastric  disturbance,  often  projectile,  resembling  that  which 
occurs  in  cerebral  disease.  The  convulsion,  a  by  no  means  con- 
stant phenomenon  when  present,  is  general,  not  localized,  as  is 
usual  in  acute  brain  troubles.  There  is  sometimes  well-marked 
tenderness  along  the  nerve-trunks,  and  even  pain  on  passive 
movement  of  a  limb,  giving  rise  to  the  suspicion  of  a  neuritis 
and  making  the  diagnosis  somewhat  troublesome.  This  was 
common  to  several  of  the  cases  in  an  epidemic  of  poliomyelitis 
seen  by  one  of  us,  occurring  in  August  of  1896,  in  Cherryfield, 
Maine. 

The  diagnosis  between  the  spinal  and  cerebral  types  of  paral- 
ysis can  oftentimes  only  be  made  in  the  light  of  subsequent  phe- 
nomena, the  form  of  palsy,  the  electric  conditions,  and  the 
atrophy.  The  palsy  at  first  is  extensively  distributed  and  may 
involve  all  four  extremities.  This  subsides  rapidly,  and  those 
parts  which  are  to  be  permanently  damaged  remain  obviously 
impaired.  The  atrophy  of  the  muscles  is  seen  sometimes  as 
early  as  the  third  day,  and  often  in  the  first  ten  days.  The 
wasting  is  in  the  line  of  distribution  of  the  loss  of  power,  and  a 
limb  or  muscle  is  readily  seen  to  be  smaller,  even  in  fat  subjects, 
than  the  corresponding  parts.  It  feels  limp,  flabby,  and  cool, 
with  vasomotor  changes  in  the  skin,  occasionally  a  notable 
cyanosis,  and  other  evidences  of  inactive  nutrition.  The  weaker 
muscles  are  at  the  mercy  of  the  stronger  ones  ;  thereby  con- 
tractures  are  produced.  Shortening  takes  place,  too,  because 
the  atrophy  involves  the  bones  also.  The  skin  frequently  ap- 
pears shriveled,  becoming  pallid,  cold,  clammy,  and  bluish.  The 
blood  supply  is  lessened,  being  no  longer  needed  to  the  full 
amount,  and  the  vessels  themselves  suffer  shrinkage. 

The  electric  reactions  are  most  important.  The  paralyzed 
muscles  and  nerves  exhibit  the  reaction  of  degeneration,  the 
anodal  closure  contraction  being  equal  to  or  greater  than  the 
cathodal  closure  contraction.  At  the  very  first  (Sachs)  the 
faradic  and  galvanic  response  may  be  increased,  soon  to  be  less- 
ened or  lost ;  the  rule  is  that  reaction  to  the  faradic  current  is 
lost  at  once,  but  to  galvanism  it  remains  or  is  increased  for  some 
time  and  then  is  lost,  except  that  it  may  appear  to  very  strong 
currents.  If  response  to  very  strong  faradic  excitation  is  re- 
tained, we  can  be  hopeful  of  restoration  to  fair  functional  power. 
If  this  is  absent  for  a  long  time,  the  power  of  these  muscles  is 


INFANTILE    SPINAL    PARALYSIS.  593 

gone.  In  the  later  stages,  also,  of  the  disease,  if  there  is  a  return 
of  faradic  response  or  a  normal  behavior  to  galvanism,  this  enables 
one  to  predict  at  least  a  partial  recovery.  The  restoration  to 
power  or  size  is  rarely  complete,  although  an  excellent  functional 
activity  may  be  regained. 

The  reflexes  are  diminished,  at  least  those  associated  with  the 
normal  function  of  the  paralyzed  part.  The  knee-jerk  is  lost  in 
the  majority  of  cases,  but  if  the  disturbance  is  in  the  upper  cord, 
it  may  persist,  and  also  if  an  isolated  muscle  or  group  of  mus- 
cles only  are  affected.  If  all  the  muscles  in  a  limb  are  palsied, 
it  hangs  entirely  limp,  like  that  of  a  doll  (the  Punchinello  leg). 
The  gait  of  a  sufferer  from  poliomyelitis,  where  one  leg  is  entirely 
flaccid,  is  thoroughly  characteristic,  and  is  much  like  that  of  a 
person  walking  on  an  artificial  limb.  Where  there  is  only  one 
or  a  few  muscles  affected,  the  gait  may  be  altered  very  little,  and 
if  the  bone  growth  is  not  interfered  with,  such  persons  enjoy 
great  activity  and  are  only  somewhat  impaired  in  power.  The 
disablement  is  not  nearly  so  great  as  in  the  spastic  type  of  cere- 
bral palsy,  where  the  usefulness  of  the  limb  is  disturbed  by  lack 
of  control  of  what  are  often  vigorous  muscles.  Permanent  over- 
action  is  shown  by  the  contraction  of  the  strong  muscles,  caus- 
ing the  weaker  ones  to  give  way,  offering  no  balancing  opposi- 
tion. Pain  may  be  present  from  the  very  first,  but  does  not  last 
long.  Usually  there  is  some  tenderness  along  the  affected  nerves. 
The  bladder  and  rectum  are  not  involved,  as  a  rule.  The  brain 
is  not  affected  at  all,  except  possibly  for  the  first  day  or  two,  and 
poliomyelitis  leaves  no  mental  defect  whatsoever. 

Prognosis  is  not  so  bad  as  is  generally  estimated,  for  while  a 
palsy  certainly  remains,  it  may  be  very  slight  and  not  disabling 
or  seriously  disfiguring.  The  more  widely  distributed  the  paral- 
ysis at  first,  the  more  serious  is  likely  to  be  the  damage.  The 
severity  of  the  onset  is  not  a  significant  index,  and  those  cases 
beginning  most  explosively  recover  surprisingly  at' times. 

In  the  first  few  weeks  little  or  no  change  may  be  expected, 
but  if  no  improvement  is  noted  in  a  muscle  or  group  of  muscles 
after  two  or  three  months,  the  outlook  for  improvement  therein 
is  gloomy. 

If  the  palsy  be  ever  so  severe  and  yet  respond  fairly  to  electric 
contractions,  much  of  betterment  may  be  hoped  for.  When  the 
response  to  faradism  can  with  difficulty  be  elicited,  the  prognosis 
is  poor ;  yet  if  this  soon  returns,  hope  again  arises.  If  this  re- 
action be  long  absent,  the  muscle  is  liable  to  remain  permanently 
paralyzed  ;  more  probably  so  if  the  reaction  of  degeneration  is 
present.  Life  is  rarely  endangered,  and  to  this  extent  the  outlook 
38 


594  DISEASES    OF    THE    NERVOUS    SYSTEM. 

is  always  good.  If  death  occurs,  it  is  in  the  earlier  weeks. 
Moreover,  the  mind  is  rarely  or  never  affected  ;  no  fear  need  be 
entertained  of  mental  degeneration,  which  always  threatens  in 
the  cerebral  palsies. 

Treatment. — Absolute  rest  and  quiet  are  needed  in  the 
acute  stage  of  this  as  of  other  inflammatory  disorders,  and  the 
attention  may  be  focused  upon  antipyresis  and  mild  revulsives — 
the  fewer  medicines  the  better,  except  to  meet  symptoms,  as 
fever  mixtures — aconite,  solution  of  ammonium  acetate,  with 
ammonium  bromid  or  antipyrin.  Salicylates  may  be  useful 
for  pain  and  muscular  tenderness.  Ergot  is  of  value  to  limit  the 
spread  of  inflammation.  The  bowels  should  be  well  opened  by 
small  doses  of  calomel,  a  saline,  or  castor  oil. 

After  a  time  the  damaged  muscles  demand  treatment ;  gentle 
massage  is  early  indicated  in  short  seances  after  the  limb  is  well 
warmed,  superficial  at  first ;  later  faradism  strong  enough  to 
contract  the  muscles,  cautiously,  and  finally  galvanism. 

Faradism  is  of  use  as  a  muscle  tonic  if  the  parts  respond  to  it 
at  all,  to  induce  action  which  the  will  can  no  longer  effect ;  if 
not,  then  galvanism  must  be  used  without  delay.  Frequent 
tests  with  faradism  are  useful  to  determine  progress,  and  this  it 
is  always  useful  to  employ  along  with  galvanism  whenever  it 
produces  contractions. 

Massage,  gradually  increased,  along  with  heat,  is  of  undoubted 
value  to  aid  nutrition,  circulation,  and  reactive  powers  in  muscle 
and  skin ;  this  overcomes  tendency  to  contractures.  Skilled 
manipulators  are  needed  for  this  to  secure  any  satisfactory  re- 
sults. Passive  movements  should  be  employed  in  all  cases  to 
prevent  the  constantly  menacing  contractures. 

Chronic  changes,  contractures,  and  the  like  should  receive  the 
most  careful  attention  from  the  orthopedist.  Tenotomies  are 
often  followed  by  brilliant  results.  Splints,  too,  are  of  great 
assistance  and  must  not  be  unduly  delayed.  Prevention  of 
contraction  is  thoroughly  feasible,  and  far  better  than  the 
overcoming  of  it  after  deformity  has  become  established. 


ACUTE  MYELITIS. 

Myelitis  is  an  inflammation  of  the  substance  of  the  spinal 
cord,  characterized  by  disturbances  in  the  motor,  sensory,  and 
trophic  centers. 

Causes. — Myelitis  may  occur  as  a  complication  of  the  acute 
infectious  diseases,  rheumatism,  exposure  to  intense  cold,  or 
sudden  changes  of  temperature  when  the  subject  is  overheated 


ACUTE    MYELITIS.  595 

or  exhausted,  and  to  atmospheric  conditions.  It  has  been  known 
to  follow  metallic  and  other  chemic  poisonings  and  overexertion  ; 
pressure  of  any  kind,  such  as  fractures  and  dislocations  ;  and  to 
arise  secondarily  to  disease  of  bones  of  the  spine,  Pott's  dis- 
ease, and  the  infectious  fevers,  neoplasms,  hemorrhage,  and 
pachymeningitis.  Very  slight  injuries  in  some  instances  seem 
able  to  cause  severe  myelitis. 

Course. — The  onset  of  myelitis,  as  a  rule,  is  rapid,  and  total 
paraplegia  is  often  established  in  a  very  few  days.  Complete 
recovery  is  rare.  Cases  may  cease  to  progress  after  a  fortnight 
or  so,  and  never  reach  any  serious  condition  of  disablement. 

Symptoms. — The  symptoms  of  acute  myelitis  vary  with  the 
site  of  the  lesion  and  intensity  of  the  process,  and  the  clinical 
features  depend  upon  the  amount  of  cord  tissue  involved.  The 
two  forms  of  myelitis  which  are  common  in  children  are  those 
which  are  due  to  syphilis  and  to  pressure  or  extension  from 
Pott's  disease  of  the  spine  ;  the  temporary  palsies  of  rickets  and 
scurvy  are  similar.  In  the  syphilitic  form  and  those  due  to 
slowly  developed  pressure  there  may  arise  indefinite  prodromes, 
such  as  slight  disorders  of  sensation  and  intermittent  weaknesses. 
A  feeling  of  great  weight  in  the  legs  may  be  experienced  ;  in  a 
few  hours  the  legs  may  become  quite  useless,  and  in  a  few  days 
entirely  palsied.  Convulsions  and  delirium  have  been  seen,  but 
are  not  common.  Pain  in  the  back  and  limbs  may  occur  if  the 
posterior  nerve-roots  are  involved. 

The  upper  limit  of  the  lesion  is  often  marked  by  a  zone  of 
hyperesthesia,  or  of  a  sensation  as  of  a  girdle  drawn  tightly 
about  the  body  ;  and  below  this  the  paralysis  can  easily  be  de- 
tected. Lesions  occurring  in  the  cervical  region  involve  the 
ciliospinal  center,  with  consequent  dilatation  of  the  pupil.  Com- 
plete transverse  myelitis,  at  whatever  level  the  area  of  inflamma- 
tion may  be,  is  exhibited  by  initial  pains,  numbness  and  tingling 
in  the  limbs,  and  within  a  few  days  disturbances  of  motion  ;  the 
reflexes  are  altered,  and  if  the  lesion  is  in  the  lumbar  region, 
control  of  the  bladder  and  rectum  is  disturbed.  Paraplegia  is 
the  characteristic  form  of  paralysis. 

In  myelitis  occurring  in  the  cervical  portion  of  the  cord  the 
paralysis  of  the  upper  extremities  will  be  of  a  flaccid  order ;  the 
paralysis  of  the  lower  extremities  will  be  spastic  in  character. 
Anesthesia  will  be  present  in  the  four  extremities  and  in  the 
trunk  to  the  level  of  the  diseased  segments  ;  pupillary  symptoms, 
unilateral  blushing  (due  to  lesion  of  the  sympathetic),  and  par- 
alysis of  the  diaphragm  are  present  in  some  cases.  "  If  the  lesion 
is  in  the  lumbar  portion  of  the  cord,  the  paralysis  is  restricted  to 


596  DISEASES    OF    THE    NERVOUS    SYSTEM. 

the  lower  extremities  and  will  be  of  a  flaccid  character,  with  more 
or  less  atrophy.  If  the  lesion  is  in  the  cervical  or  dorsal  portion 
of  the  cord  and  the  lumbar  portion  is  entirely  free  from  disease, 
the  paraplegia  of  the  lower  extremities  is  of  the  spastic  order ; 
and  the  reason  of  this  can  be  easily  understood  if  we  recall  the 
fact  that  after  a  transverse  lesion  of  any  portion  of  the  spinal 
cord  the  lateral  columns  will  degenerate  downward  from  that 
level,  and  that  such  degeneration  of  the  lateral  columns  in  the 
presence  of  normal  gray  matter  of  the  lumbar  segments  will  pro- 
duce a  spastic  form  of  paralysis  with  rigidities  and  contractures  " 
(Sachs). 

Alterations  of  sensation  are  present  from  the  start ;  areas  of 
anesthesia  will  afford  some  clue  to  the  situation  of  the  lesion. 
At  the  upper  limit  of  the  area  of  lost  sensation  a  zone  of  hyper- 
esthesia  may  be  found  ;  above  this,  normal  sensation  appears. 
In  other  cases  a  girdle  sensation  marks  the  level  between  the 
normal  and  the  diseased  segments. 

The  state  of  the  reflexes  helps  us  also  to  determine  the  area 
involved.  We  quote  from  Sachs  again  :  "  If  the  lesion  is  in  the 
cervical  region,  all  the  reflexes  of  the  upper  extremities  are  lost ; 
those  in  parts  below  will  be  exaggerated.  If  the  lesion  is  in  the 
dorsal  region,  the  reflexes  connected  with  these  segments,  such  as 
the  abdominal  and  epigastric  reflexes,  will  be  lost  and  the  lower 
reflexes  will  be  increased.  If  the  lesion  is  in  the  lumbar  region, 
the  knee-jerk  will  be  lost  and  the  ankle-clonus  will  be  absent 
also.  In  some  cases  in  which  there  is  a  very  narrow  band  of 
inflammation  these  reflexes  may  behave  differently  and  may  give 
one  a  direct  clue  as  to  the  exact  extent  of  spinal  inflammation." 

It  is  common  to  find  exaggerations  of  reflexes  along  with 
spastic  contractures  of  the  legs.  For  explanation  of  the  phe- 
nomena of  reflexes  the  reader  is  referred  to  the  article  at  the 
beginning  of  this  chapter.  Electric  reactions  vary  according  to 
the  segments  involved.  The  reaction  of  degeneration  will  be 
found  in  most  of  the  muscles  of  the  upper  extremities  in  cases  of 
cervical  lesion,  while  those  in  the  lower  extremities  are  unaltered. 
In  lesions  of  the  lumbar  segments  degenerative  changes  follow 
muscles  supplied  by  nerves  coming  from  the  diseased  area.  In 
the  muscles  of  the  lower  extremities  the  reaction  is  normal  in 
cases  of  cervical  and  dorsal  myelitis.  The  centers  controlling 
the  bladder  and  rectum  are  profoundly  disturbed,  resulting  in 
retention  of  urine  or  overflow  dribbling,  and  in  retention  or  loss 
of  control  over  the  rectal  sphincter.  Priapism  is  sometimes  an 
annoying  symptom,  as  are  also  involuntary  spasmodic  twitchings, 
the  latter  resulting  from  very  slight  sensory  impressions.  A 


ACUTE    MYELITIS.  597 

slight  touch  may  cause  a  large  contraction  of  the  entire  limb. 
Bed-sores  are  formed  from  the  very  smallest  causes,  and  must 
be  assiduously  guarded  against  in  every  way.  Fever  occurs  in 
every  form  of  acute  myelitis,  but  may  be  complicated  by  other 
causes  present.  The  most  important  point  to  determine  is  the 
cause.  In  the  absence  of  other  known  origin  slight  traumata 
may  be  suspected ;  mere  concussion  may  suffice.  Those  in- 
stances due  to  pressure,  such  as  of  tumors,  tubercular  deposits, 
syphilitic  infection,  and  Pott's  disease,  are  very  distinct  and  have 
been  alluded  to. 

Pathology. — It  is  exceedingly  difficult  to  explain  why  the 
structure  of  the  spinal  cord  should  be  so  extremely  liable  to 
inflammatory  disease,  and  why  the  dorsal  portion  should  be 
more  frequently  attacked  than  the  cervical  or  lumbar  enlarge- 
ments. The  gross  appearances,  seen  postmortem,  show  the 
cord  to  be  surrounded  by  hyperemic  meninges,  and  the  cord 
itself  congested  or  swollen.  The  cord  substance  may  be  softer 
than  normal,  or  even  reduced  to  a  creamy  pus,  which  flows  out 
readily.  There  may  be  minute  hemorrhages  or  red  softening, 
and  every  degree  of  change  between  this  and  such  a  degree  of 
extravasation  of  blood  as  obscures  all  other  changes.  Micro- 
scopically there  may  be  seen  dilated  blood-vessels,  with  leu- 
kocytes, granules  of  myelin,  corpora  amylacea,  and  axis-cylinders 
in  various  stages  of  disintegration.  Whether  fibers  that  have 
once  been  seriously  altered  can  ever  recover  is  open  to  grave 
doubt,  yet  in  a  fair  number  of  cases  recovery  is  excellent. 
Conservative  vicarious  action  of  remaining  normal  fibers  prob- 
ably accounts  for  this  functionation  where  part  of  the  cord  is 
destroyed. 

Prognosis. — Naturally,  the  higher  up  the  myelitis,  the  more 
is  it  likely  to  be  dangerous  to  respiratory  and  cardiac  centers. 
The  perils  in  all  cases  arise  chiefly  from  the  complicating  condi- 
tion, particularly  vasomotor  disturbances  and  bladder  and  kidney 
involvement.  If  the  myelitis  is  due  to  syphilis,  a  moderate  toxic 
infection,  or  slight  pressure  from  a  curable  Pott's  disease,  the 
possibilities  for  recovery  are  good.  The  lessening  of  anesthesia 
is  a  fair  index  of  improvement,  and  deep  bed-sores  beginning 
early  are  almost  a  fatal  sign. 

Treatment. — The  treatment  for  myelitis  is  much  the  same  as 
that  for  meningitis  ;  the  main  objects  are  to  avoid  complicating 
conditions  and  to  relieve  the  diseased  organs  of  all  strain.  The 
first  requisite  is  absolute  rest,  on  a  water-bed  if  possible.  The 
bowels  should  be  purged,  best  by  calomel,  which  also  acts  as  a 
valuable  diuretic.  Some  form  of  extension  should  be  used  from 


598  DISEASES    OF    THE    NERVOUS    SYSTEM. 

the  first ;  we  have  devised  a  very  simple  measure  for  this,  con- 
sisting of  a  towel  folded  lengthwise  to  about  three  inches  in  width, 
and  pinned  with  two  safety-pins  at  the  ends,  making  a  ring  large 
enough  to  just  slip  over  the  head  ;  this  adjusted  under  the  chin  and 
back  of  the  head  and  caught  on  the  two  sides  opposite  each  ear 
by  a  piece  of  bandage,  forming  a  loop  of,  perhaps,  two  feet  in 
length,  extending  to  nearly  the  head  of  the  bed,  there  to  meet 
a  piece  of  small  rope  and  to  hang  over  and  down,  and  become 
attached  to  a  weight,  such  as  a  flat-iron.  This  is  a  very  simple 
device,  and  yet  has  again  and  again  proved  a  very  efficient  one, 
and  can  be  made  by  careful  readjustment  to  act  even  better  than 
an  expensive  apparatus.  Counterextension,  if  required,  is  easily 
obtained  by  elevating  the  head  of  the  bed.  The  diet  should  be 
chiefly  of  milk,  soups,  and  other  substances  suited  to  inflamma- 
tory states,  bearing  in  mind  the  vulnerability  of  the  bladder.  The 
water  should  be  drawn  by  catheter,  but  excessive  care  should  be 
used  to  avoid  producing  the  ever  imminent  cystitis.  Should  this 
last  occur,  the  bladder  should  be  washed  out  two  or  three  times 
a  day  with  sterilized  water  or  with  boric  acid  solution.  A  very 
important  point  is  to  make  sure  that  the  nurse  allows  no  wrink- 
ling of  the  bed-linen  on  which  the  patient  lies,  who,  no  longer 
defended  by  acute  cutaneous  sensibility,  and  the  vasomotor  tone 
in  the  anesthetic  areas  being  lost,  easily  suffers  serious  trouble  to 
his  skin.  Should  bed-sores  begin  to  form,  carefully  adjusted 
antiseptic  dressings  should  be  used  at  once.  Dusting-powders 
are  here  of  use — acetanilid,  thymol  diiodid,  aristol,  and  the  like. 
When  the  urine  dribbles  away,  instant  care  should  be  taken  to 
catch  it  in  some  vessel,  or,  perhaps  better,  ample  masses  of  borated 
absorbent  cotton  or  antiseptic  gauze.  Medicines  are  of  doubtful 
utility,  except  for  symptomatic  relief,  such  as  digitalis,  acetate  of 
potash,  urotropin,  or  other  diuretics  and  diluents  ;  the  iodids  are 
useful  in  syphilitic  cases  and  may  assist  in  eliminating  inflamma- 
tory exudate  ;  especially  are  the  iodids  useful  in  the  subacute 
stages  of  the  malady,  and  should  at  least  be  tried  repeatedly, 
unless  found  disturbing  to  the  digestion.  Should  these  be  un- 
availing, inunctions  of  mercury  may  be  substituted  with  good 
effect.  Electricity  is  of  little  use  to  the  spinal  cord,  but  is 
valuable  for  the  paralyzed  muscles.  Massage  may  be  tried  more 
hopefully,  and  should  be  used  just  as  early  as  is  feasible.  By 
this  means  preparations  of  oil  may  be  rubbed  in  and  thus  aid 
nutrition  daily.  If  involuntary  contractions  complicate  the  case, 
as  is  only  too  common,  the  person  giving  massage  must  use  slow, 
firm  strokings  and  gentle  overextensions,  which  have  a  tendency 
to  overcome  this  trouble.  Strychnin  must  be  used  cautiously 


DISSEMINATED    SCLEROSIS.  599 

and  is  not  so  safe  a  remedy  as  is  generally  thought.  Im- 
mediately convalescence  is  well  established,  every  effort  should 
be  made  to  secure  as  much  fresh  air  as  possible.  This  should 
be  done  quite  early  by  using  additional  coverings,  especially  over 
the  head,  and  opening  wide  the  windows,  which  is  the  next  best 
thing  to  getting  outdoors.  Of  especial  importance  here,  too,  is 
tonic  treatment  for  the  skin,  in  the  way  of  baths,  hot  and  cold 
douches  to  the  spine,  adding  salt  to  the  water,  aromatic  vinegar, 
or  the  aromatic  sulphuric  acid,  and  following  by  oily  inunctions. 
Counterirritation  over  the  spine  in  prolonged  mild  cases  of 
myelitis  may  greatly  ease  pain  and  exert  some  favorable  influence 
on  the  inflammation. 


DISSEMINATED  SCLEROSIS. 

Disseminated,  insular,  or  cerebrospinal  sclerosis  is  a  disease  of 
early  life,  characterized  by  a  definite  set  of  symptoms  consisting 
of  tremor,  difficult,  deliberate  speech,  ocular  symptoms,  and  a 
peculiar  gait,  but  with  great  variation  in  the  phenomena. 
Anatomically,  areas  of  sclerosis  of  varying  sizes  are  found  scat- 
tered through  the  brain  and  cord. 

Causes. — Disseminated  sclerosis  in  children  occurs  most  often 
as  a  sequel  of  the  infectious  diseases,  after  traumata,  overwhelm- 
ing emotion,  or  possibly  following  metallic  poisoning.  It  is 
more  common  in  adolescents,  and  yet  not  rare  in  children. 
It  is  much  more  likely  to  arise  in  those  of  neurotic  heredity, 
and  is  oftener  met  in  Europe  than  in  this  country. 

Symptoms. — The  disease  usually  begins  by  a  gradual  weak- 
ness in  the  arms,  fingers,  and  legs,  with  irregular  pains  and 
stiffness  and  an  intention  tremor,  increased  on  effort,  gradually 
increasing.  This  tremor  subsides  when  the  parts  are  at  rest, 
becomes  marked  on  exertion,  and  grows  worse  under  coordinate 
acts  and  excitement.  It  often  increases  in  intensity  and  extends 
to  the  legs,  producing  great  difficulty  in  locomotion.  The 
articulation  becomes  deliberate — "  scanning  speech,"  pronounc- 
ing each  syllable  slowly  and  laboriously,  like  a  child  reading 
from  a  primer.  There  may  be  a  distinct  vibratile  quality  of 
the  voice.  The  tremor  at  times  affects  the  muscles  of  the  eye, 
producing  a  nystagmus  which  is  increased  by  looking  forcibly 
to  right  or  left ;  the  field  of  vision  is  narrowed,  the  color-fields 
altered,  quite  similar  to  the  changes  produced  in  hysteria.  The 
tongue  upon  protrusion  also  exhibits  a  tremor,  and  the  expres- 
sion of  the  face  becomes  stupid  and  uncertain.  The  mental 
condition,  especially  memory,  is  impaired,  and  the  sufferer  is 


6OO  DISEASES    OF    THE    NERVOUS    SYSTEM. 

exceedingly  emotional,  especially  when  the  disease  has  begun 
early  in  life. 

The  paralysis  is  of  the  spastic  order,  showing  in  the  gait  a 
dragging,  shuffling,  springy  motion  of  the  legs  (causing  the  shoes 
to  wear  through  quickly  in  the  toe  part  of  the  soles),  due  to 
rigidity  and  contractures.  Athetosis  is  not  uncommon.  The 
deep  reflexes  are  increased,  and  the  muscles  become  rigid. 
These  phenomena  may  remain  much  the  same  for  a  long  period, 
and  yet  tend  finally  to  grow  worse.  The  memory  weakens, 
speech  becomes  unintelligible,  and  finally  all  the  voluntary  ac- 
tivities fail ;  sensation  is  little  affected  ;  death  usually  occurs  from 
some  intercurrent  disease. 

Pathology. — In  disseminated  sclerosis  there  are  found  plaques 
of  sclerotic  tissue  distributed  irregularly  throughout  the  greater 
part  of  the  central  nervous  system.  These  patches  of  firm 
gray  tissue  appear  in  the  brain  as  well  as  in  the  spinal  cord, 
and  may  appear  first  in  the  one  or  the  other.  Whether  the 
hardening  shows  in  the  nervous  centers  or  in  the  fibers  emerg- 
ing from  them,  the  character  of  the  changes  is  much  the  same, 
the  important  point  to  keep  in  view  being  that  only  some,  and 
not  the  majority,  of  the  nerve-fibers  are  destroyed,  .thus  produc- 
ing a  perverted  action  of  the  whole  cerebrospinal  system. 

Prognosis. — Multiple  sclerosis  is  a  chronic  disorder,  and  in- 
duces death  more  by  depreciating  the  entire  organism  and  by 
adding  an  element  of  peril  through  increasing  susceptibility  to 
disease  than  by  itself  terminating  life.  If  the  vital  centers  are 
affected,  death  may  be  caused  by  this  process  directly.  The 
progress  is  slow  and  quite  incurable,  but  may  in  some  instances 
come  to  a  standstill  for  years.  We  have  had  under  observation 
a  family  of  many  children  in  which  three,  and  possibly  four,  are 
affected  by  this  disease,  and  from  a  very  early  age.  One  of 
these,  a  boy,  served  us  in  the  capacity  of  errand  boy  for  some 
months.  They  are  all  still  living,  though  the  oldest  sufferer, 
aged  about  twenty -three,  is  now  bedridden. 

Treatment. — The  disease  is  quite  incurable,  but  many  meas- 
ures are  of  distinct  value  in  enhancing  the  comfort  of  the  sufferers. 
Prolonged  rest,  with  systematic  hygienic  measures,  benefits  ex- 
ceedingly. The  process  is  very  exhausting  to  the  victims. 
There  is  a  perpetual  unrest,  which  needs  to  be  met  by  unremit- 
ting reparative  measures.  Sleep  is  oftentimes  much  disturbed, 
and  tepid  baths  at  night  contribute  largely  toward  general  con- 
tentment. Cool  and  colder  douches  are  useful  during  the  day, 
or  the  drip  sheet,  the  patient  standing  in  warm  water.  Electricity 
is  of  little  use  to  the  muscles — the  constant  current  is  valuable 


HEREDITARY    ATAXIA.  6oi 

applied  to  the  spine.  Mild  galvanism  moved  up  and  down  the 
back  may  be  tried  most  hopefully.  Manipulations  of  the  limbs 
will  do  much  toward  relieving  the  contractures.  It  should  be 
borne  in  mind  that  in  giving  massage  to  spastic  limbs,  slow,  firm 
movements  are  best ;  also,  as  demonstrated  long  ago  by  Mitchell, 
overextensions  of  the  limbs  tend  to  overcome  contracture,  lessen 
tremor,  and  make  the  parts  more  elastic. 

Medicinal. — lodids  and  mercury  have  not  the  slightest  effect, 
but  arsenic  is  recommended,  and  a  prolonged  course  of  nitrate  of 
silver  may  be  tried.  For  the  tremors,  bromids,  hyoscin,  hyoscy- 
amin,  gelsemium,  cannabis  indica,  and  belladonna  exert  some 
relief. 

If  contractures  become  extreme,  and  especially  if  they  impede 
locomotion  by  malposition  of  the  feet,  tenotomy  may  greatly 
aid  in  getting  the  patient  to  move  about  with  more  freedom  and 
ease. 

HEREDITARY  ATAXIA. 

Hereditary  ataxia,  known  also  as  Friedreich's  disease,  is  a 
form  of  spinal  hardening  appearing  usually  in  children,  and 
with  distinct  hereditary  features.  It  is  to  be  recognized  by  a 
wide -spread  ataxia,  beginning  in  the  legs,  by  impairment  of 
speech,  and  by  nystagmus.  The  course  pursued  is  a  progres- 
sive one.  There  are  many  symptoms  which,  while  sometimes 
absent,  yet  assist  in  giving  a  definiteness  to  the  diagnosis.  The 
cause  is  a  very  striking  one  of  hereditary  transmission  during 
several  generations.  This  may  be  in  the  same  form,  or  by 
analogous  scleroneurotic  diseases.  The  susceptibility  increases 
in  the  later  generations,  and  those  attacked  are  progressively 
younger.  The  defective  development  is  rendered  conspicuous  by 
this — showing  or  seeming  to  show  that  portions  of  the  nervous 
system,  especially  the  spinal  cord,  are  incapable  of  sustaining 
their  normal  action  and  undergoing  sclerotic  change.  Some- 
times it  is  transmitted  mare  from  one  sex  than  the  other  in  one 
family,  but  in  the  next  instance  the  reverse  appears  ;  the  histologic 
changes  in  the  spinal  cord  are  pretty  much  the  same  as  those 
which  occur  in  locomotor  ataxia. 

The  symptoms  are  those  of  profound  awkwardness,  with  a 
tendency  to  fall  upon  slight  provocation.  The  knee-jerk  is  lost 
very  early,  as  a  rule ;  in  certain  cases,  however,  this  is  increased. 
The  superficial  reflexes  are  present  or  absent  about  equally. 
Sexual  power  is  lost  soon  or  late,  hence  descent  in  the  male  line 
is  rarer.  Romberg's  symptom  (standing  unsteady  or  swaying 
with  the  eyes  closed)  is  usually  present,  and  more  marked 


6O2  DISEASES    OF    THE    NERVOUS    SYSTEM. 

by  an  exaggerated  sway  or  total  inability  to  stand,  and  this 
progresses  steadily ;  after  a  time  the  upper  limbs  and  neck 
become  involved,  rendering  the  patient  helpless  and  losing  con- 
trol of  the  head.  Speech  is  likewise  modified  by  the  loss  of  all 
muscular  power.  Nystagmus  is  usually  present,  although  not 
constantly,  and  must  be  watched  for.  There  is  little  or  none  of 
the  sensory  disturbances  seen  in  locomotor  ataxia.  The  power 
of  the  muscles  is  much  reduced,  but  actual  paralysis  comes  on 
very  late  and  is  of  only  moderate  extent.  Sometimes  coarse 
tremor  is  present,  amounting  to  choreoid  movements  of  the 
head  and  legs.  The  face  has  a  somewhat  characteristic  expres- 
sion, is  stolid,  heavy,  with  dropped  jaw  and  mouth  partly  open. 
The  course  of  the  disease  is  chronic,  death  resulting  from  inter- 
current  maladies.  Some  cases  have  lived  to  a  considerable  old 
age,  and  others  have  been  discovered  only  in  their  later  years. 

The  diagnosis  is  made  upon  the  youthfulness  of  the  patient, 
slowness  of  the  onset,  the  family  history  showing  similar  cases 
or  instances  of  spinal  sclerosis  and  predementia  or  direct  fea- 
tures of  the  ataxia — nystagmus,  peculiar  halting  speech,  and, 
to  a  certain  extent,  facial  expression.  The  pains  of  locomotor 
ataxia  are  absent,  also  the  peculiar  pupillary  symptoms  of  that 
disease. 

The  treatment  is  altogether  unsatisfactory.  Those  measures 
recommended  in  locomotor  ataxia  may  be  used,  and  general 
tonic  and  nutritional  measures  are  demanded.  Above  all,  much 
solicitude  should  be  exercised  to  afford  a  reasonable  amount  of 
instruction,  so  that  these  unfortunate  beings  should  possess  some 
source  of  amusement  or  occupation  through  their  long  and 
miserable  existence. 


PROGRESSIVE  MUSCULAR  ATROPHIES. 

An  interesting  group  of  disorders  is  that  of  the  muscular 
atrophies.  Some  of  these  are  peculiar  to  childhood  and  less 
rare  than  has  been  for  a  long  time  believed.  The  important 
point  to  make  clear  in  each  case  is  whether  it  is  due  to  spinal 
origin  or  is  simply  a  muscular  degeneration.  The  muscular 
atrophies  of  spinal  origin  are  called  amy  atrophies  ;  those  of  mus- 
cular origin,  myopathies.  The  term  dystrophy  has  been  restricted 
to  primary  muscular  wasting. 


PSEUDOHYPERTROPHIC    MUSCULAR    PARALYSIS.  603 


PSEUDOHYPERTROPHIC  MUSCULAR  PARALYSIS. 

This  myopathy  is  a  disease  of  early  childhood,  characterized 
by  progressive  loss  of  power  in  certain  muscles  and  groups  of 
muscles,  which  increase  in  size  and  yet  are  actually  weak. 
Atrophy  of  the  affected  muscles  finally  supervenes. 

The  general  symptoms  are  those  of  clumsiness  and  increase 
in  the  size  of  the  muscles  affected,  the  child  falling  readily  and 
getting  upon  its  feet  with  great  difficulty.  The  muscles  of  the 
lower  limbs  are  those  chiefly  affected,  but  certain  muscles  of  the 
arms  are  also  involved  at  times,  those  of  the  hand  and  forearm 
especially.  The  attitude  is  very  characteristic :  the  legs  are 
always  held  wide  apart  and  the  trunk  is  very  erect,  with  the  back 
usually  hollow,  amounting  often  to  a  lordosis.  The  gait  is  a 
slow,  wide-sprawling  action,  the  feet  being  put  down  with  great 
deliberation  and  the  balance  laboriously  maintained.  One  of  the 
most  characteristic  signs  of  the  diseased  condition  is  the  manceu- 
vers  executed  by  the  child  in  rising  from  the  floor  and  getting 
upon  its  feet.  This  is  as  follows  :  The  child,  lying  upon  its  back, 
rolls  over  on  its  side  with  more  or  less  difficulty,  and  having 
straightened  out  its  hands  and  feet  in  the  position  of  "  all  fours," 
commences  with  great  straining  action  to  struggle  finally  to  a 
position  in  which  the  knees  are  extended ;  then,  watching  its 
opportunity,  it  seizes  one  of  its  knees  with  the  corresponding 
hand,  throwing  the  head  back,  and  catching  the  other  knee  with 
its  corresponding  hand,  and  then  straightening  the  body. 

The  tendon-jerks,  as  a  rule,  are  unaltered,  except  that  they 
exhibit  a  greater  feebleness  and  are  finally  lost.  Sensation  is 
impaired,  also  the  mental  activity,  as  a  rule.  There  are  often 
slight  vasomotor  disturbances,  shown  by  a  mottling  of  the  skin 
of  the  legs.  The  cause  of  the  malady  is  admitted  to  be  heredi- 
tary influence  in  most  instances,  and  always  through  the  mother, 
who  herself  may  show  no  evidence  of  the  disease  but  transmits 
this  developmental  defect.  While  recognized  after  puberty  has 
set  in,  it  is  reasonable  to  assume  that  the  disease  was  in  evidence 
before  that  time. 

Pseudomuscular  hypertrophic  paralysis  is  now  generally  con- 
ceded to  be  primarily  a  disease  of  the  muscles,  an  idiopathic 
myopathy. 

The  pathology  of  the  disease  is  obscure — a  degenerative 
change  in  the  muscular  tissue  itself,  a  trophoneurosis.  Along 
with  this,  or  following  soon  after,  is  a  change  in  the  connective 
tissue,  which  is  both  infiltrated  with  fat  and  increased  in  bulk, 
and  to  this  is  attributed  much  of  the  hardness  of  the  muscles. 


604  DISEASES    OF    THE    NERVOUS    SYSTEM. 

The  diagnosis  of  this  condition  is  not  at  all  difficult  when 
once  the  overdeveloped  muscles  become  well  marked.  If  this 
phenomenon  has  not  become  conspicuous,  the  peculiar  attitudes 
in  lying  and  rising  will  give  pretty  complete  evidence  of  the 
disease,  whose  main  features  depend  upon  the  weakening  of  the 
muscles  involved  in  those  acts.  It  is  well  described,  in  brief,  as 
a  slow  and  tedious  climbing  up  the  legs.  Chronic  neuritis  is 
accompanied  by  fibrillary  contractions  and  the  reaction  of  de- 
generation, both  of  which  are  absent  in  this  disease.  It  seems 
scarcely  possible  that  spastic  paraplegia  could  be  confused  with 
pseudomuscular  hypertrophic  paralysis,  and  yet  this  has  occurred. 
In  the  spastic  condition  the  strength  of  the  muscles,  usually 
with  wasting  and  great  exaggeration  of  knee-jerk  and  the  pres- 
ence of  ankle-clonus,  makes  a  conspicuous  contrast. 

The  prognosis  is  altogether  unfavorable,  but  those  who  are 
cared  for  best  will  live  the  longest. 

Treatment  is  merely  symptomatic  and  tonic.  Systematic 
massage  continued  for  many  months  has  markedly  improved 
several  cases  under  our  observation.  Electricity  is  of  less  ser- 
vice. 


CHAPTER  XV. 
THE  SPECIFIC  INFECTIOUS  DISEASES. 


TUBERCULOSIS. 

Tuberculosis  is  a  specific  infectious  disease  due  to  the  presence 
in  the  system  of  the  bacillus  tuberculosis,  discovered  by  Koch  in 
1882.  It  is  characterized  by  the  formation  of  small  nodular 
bodies  around  an  irritated  point,  the  center  of  which  is  the 
tubercle  bacillus.  The  process  is  the  product  of  a  local  inflam- 
mation, and  may  be  acute  or  chronic,  resulting  in  specific  toxins, 
causing  an  irregular  febrile  movement  and  the  formation  of  new 
and  easily  degenerated  tissue,  called  tubercle,  which  may  become 
so  much  further  weakened  as  to  be  described  as  caseous.  It  is 
met  with  in  nearly  all  parts  of  the  globe,  and  is  more  destructive 
to  human  life  than  any  other  one  disease,  "  causing  about  14  per 
cent,  of  all  deaths — more  than  the  aggregate  from  all  the  com- 
moner infectious  diseases,  including  Asiatic  cholera  and  leprosy." 
Tuberculosis  is  now  almost  universally  regarded  as  contagious, 
infectious,  or  both,  and  prevails  not  only  in  man,  but  in  many 
animals,  and  may  be  acquired  by  inheritance,  inhalation,  swal- 
lowing, and  by  inoculation.  The  contagion  of  tuberculosis  is  of 
a  slow  and  insidious  kind,  and  there  must  be  a  suitable  ground 
for  its  growth  and  a  fairly  large  amount  of  the  morbid  material 
for  it  to  grow  upon.  While  to  other  contagious  and  infectious  dis- 
orders there  may  come  an  acquired  immunity,  there  is  a  tendency 
in  tuberculosis,  when  begun,  to  steadily  and  rapidly  progress. 
The  presence  of  the  bacillus  tuberculosis  in  whatsoever  secre- 
tion or  tissue  of  the  body  is  an  infallible  indication  of  infection 
by  the  disease,  and  there  is  practically  no  limitation  to  its  exten- 
sion. Infection  does  not  necessarily  mean  the  establishment  of 
a  progressive  and  fatal  disease.  In  many  cases  a  natural  and 
spontaneous  cure  is  effected,  when  favorable  conditions  for  the 
development  of  the  disease  are  not  present  nor  continuously 
maintained.  There  may  also  occur  spontaneous  arrest,  even 
after  the  symptoms  have  declared  themselves,  the  process 
becoming  quiescent  under  favorable  circumstances.  It  is  prob- 

605 


606  THE    SPECIFIC    INFECTIOUS    DISEASES. 

ably  not  so  prevalent  or  so  deadly  among  children  in  this 
country  as  in  Europe.. 

Causes. — The  direct  and  exciting  cause  of  tuberculosis  is  the 
tubercle  bacillus  of  Koch,  which  gains  entrance  into  the  system 
— (i)  by  direct  transmission  (parental) ;  (2)  by  inhalations,  dried 
sputum  floating  in  the  air,  dust  being  a  collateral  medium  of  con- 
tagion ;  (3)  through  infected  milk  and  meat  of  tubercular  cows 
and  food  animals ;  (4)  through  kissing,  especially  where  the 
practice  prevails  widely  between  families  and  friends. 

Tuberculosis  may  be  congenital.  Lehman  reports  a  case  in 
which  the  tuberculous  mother  died,  three  days  after  the  birth  of 
her  child,  of  tuberculous  meningitis,  the  child  living  but  twenty- 
four  hours.  In  its  spleen,  lungs,  and  liver  were  found  nodules 
resembling  tubercles  and  containing  tubercle  bacilli  in  large  num- 
bers. Birch-Hirchfield  reports,  a  similar  case. 

Tuberculosis  is  extremely  rare  in  the  new-born  and  uncommon 
in  the  first  three  months  of  life,  increasing  in  frequency  toward 
the  end  of  the  first  and  during  the  second  year.  It  is  often  met 
from  the  third  to  the  fifteenth  year.  Among  children  its  seat  is 
more  commonly  in  the  bronchial  glands,  lymph-nodes,  lungs, 
and  bones ;  it  is  also  found  in  the  pleura,  brain,  stomach,  intes- 
tines, the  large  viscera,  heart,  and  skin. 

Certain-  individuals  among  animals  and  men  are  more  sus- 
ceptible to  tubercular  poison  than  others.  This  susceptibility 
may  be  inherent  or  acquired.  Some  races  of  both  animals  and 
men  exhibit  a  marked  predisposition  to  this  disease,  which 
among  these  individuals  is  propagated  with  great  readiness  and 
develops  with  extreme  virulence.  Among  races  and  families  in 
whom  there  may  be  no  general  predisposition  there  are  occa- 
sionally seen  individuals  who  are  distinctly  more  receptive  or  less 
capable  of  resisting  the  infection  than  others  ;  and  since  the  time 
of  Hippocrates  people  of  a  certain  type  of  body,  as  described 
by  him,  are  believed  to  be  prone  to  tuberculous  disorders.  This 
is  especially  true  among  children  in  whom  classic  types  of  con- 
formation are  recognized,  as  the  "tuberculous"  with  thin  skins, 
long,  slender  bones,  light  hair,  bright  eyes,  and  oval  faces  ;  and 
the  "  scrofulous,"  with  chunky  figures,  dense,  muddy  skins,  thick 
lips,  heavy  features,  and  large  bones.  Certain  organic  defects 
seem  to  render  their  possessors  more  susceptible,  such  as  a  con- 
tracted thorax,  with  limited  respiratory  capacity,  small  and  feeble 
hearts,  narrow  arteries,  and  relatively  large-sized  viscera.  Cer- 
tain local  conditions  in  children  are  potent  predisposing  causes, 
such  as  catarrhal  conditions  of  the  throat  and  upper  air-passages  ; 
also,  dilatation  of  the  bronchi  and  existing  pleurisy,  disease 


r-tf 


TUBERCULOSIS. 


o, 


607 


of  the  stomach  and  intestines,  especially  where  there  is  I'orig- 
standing  enterocolitis.  Tuberculosis  in  children  is  especially 
liable  to  follow  the  infectious  diseases,  particularly  measles, 
whooping-cough,  and  influenza.  Various  depressing  causes 
lower  the  resistance  of  the  individual  to  this  poison,  among  which 
syphilis,  typhoid  fever,  and  smallpox  are  prominent  ;  also 
chlorosis  and  anemia,  along  with  unhygienic  environment, 
nutritional  depravity,  and  inherited  vulnerability  of  tissues. 

Hereditary  predisposition  has  long  been  regarded  as  a  pow- 


FIG.  39.  —  TUBERCULOSIS  OF  THE  LUNGS  DEVELOPED  DURING  TYPHOID  FEVER. 


erful  factor  in  the  transmission  of  tuberculosis.  It  may  be 
regarded  as  a  varying  constitutional  quality,  a  "  type  of  tissue 
soil"  which  favors  the  development  of  the  disease  provided 
accidental  infection  occurs.  Others  argue  against  this  belief, 
asserting,  on  the  other  hand,  that  an  immunity  may  be  thus 
transmitted.  The  long  incubation  period,  of  thirty  days  or 
more,  under  most  favorable  conditions,  and  the  fact  that  the 
infective  agent  may  lie  dormant  for  months  or  years  in  the 
tissues  which  have  a  meager  blood  supply,  and  later,  under 


,AC 

.  ^-vV         ,,Vv\x 
0  3  >.\  c 

THE    SPECIFIC    INFECTIOUS    DISEASES. 

suitable  conditions,  becoming  vigorously  active,  and  the  peculiar 
phenomena  which  are  finally  exhibited  in  certain  families,  make 
a  ground  for  conjectural  rather  than  scientific  conclusions.  Con- 
genital tuberculosis  is  very  rare,  and  in  all  the  reported  cases 
is  directly  maternal,  no  evidence  being  adduced  that  a  tubercu- 
lous father  can  directly  transmit  the  disease.  The  children  of 
tuberculous  parents  most  frequently  exhibit  the  disease,  but  are 
thus  constantly  and  intimately  exposed  to  infection.  Wherever 
the  individuals  are  restricted  in  the  matter  of  fresh  air,  sunlight, 
and  exercise,  there  is  greater  prevalence  of  tuberculosis.  Local 
epidemics  of  this  disease  occur  in  all  communities.  In  Philadel- 
phia, in  certain  wards  of  the  city,  it  is  shown  to  be  particularly 
prevalent, especially  in  previously  infected  or  badly  situated  houses 
(Flick).  The  air  breathed  out  by  tuberculous  patients  is  con- 
sidered harmless,  but  a  large  danger  exists  in  their  sputum,  dried 
and  pulverized  and  scattered  about.  Food  is  a  common  but 
'perhaps  exaggerated  means  of  tuberculous  infection,  especially 
the  milk  of  tuberculous  cows,  rendering  it  absolutely  essential 
that  systematic  sanitary  inspection  of  all  animal  foods  should  be 
rigid  and  constant.  It  is  not  certain  whether  the  milk  of  a 
tuberculous  woman  is  virulent  or  not ;  happily  the  mere  swallow- 
ing of  tuberculous  milk,  cream,  butter,  or  meat  is  only  a  relative 
danger,  other  conditions  being  necessary  for  infection,  whether 
local  traumatisms  or  merely  a  marked  susceptibility.  Certain 
general  conditions  strongly  influence  infection,  especially  environ- 
ment. The  disease  prevails  in  crowded  centers,  where  contact 
among  individuals  is  more  direct,  along  with  many  devitalizing 
influences,  among  which  severe  or  prolonged  nervous  strains 
are  important,  and  restricted  opportunities  for  movement  and 
change.  The  situation  of  the  house,  the  common  living-rooms, 
the  soil,  cold  and  dampness,  elevation,  and  the  like,  are  potent 
factors  in  tuberculous  propagation  or  resistance.  In  infancy  infec- 
tion is  demonstrated  to  be  through  the  respiratory  tract,  shown  by 
the  common  distribution  of  the  primary  lesions.  Infection  through 
the  alimentary  tract  is  much  less  certain  or  frequent.  A  meat 
diet  is  much  more  generally  used  in  the  latter  half  of  the  cen- 
tury than  the  first,  yet  tuberculosis  is  shown  to  be  now  far  less 
prevalent  than  then.  Tabes  mesenterica,  which  is  the  chief 
manifestation  of  tuberculosis  in  infancy,  has  not  lessened  during 
the  epoch  of  improved  sanitation,  which  is  also  marked  by  the 
increased  consumption  of  milk  as  an  infant  food.  In  both  the 
respiratory  and  the  gastro-intestinal  tract  some  lesion  of  the 
mucous  surfaces  is  necessary  for  the  ready  acceptance  of  the 
poison.  Even  then  the  bacillus,  when  lodged  in  the  adjacent 


GENERAL   TUBERCULOSIS.  609 

lymph-nodes,  may  there  remain  inert.  Treves  and  Holt  maintain 
that  tuberculosis  of  the  cervical  lymph-nodes  is  rarely  a  source 
of  further  extension  of  the  disease,  though  Jacobi  makes  much 
of  the  latent  danger  of  spread  from  this  source.  Inflammation 
and  acute  febrile  conditions  may,  however,  stir  up  this  dormant 
infection  and  cause  wide-spread  disease. 


GENERAL  TUBERCULOSIS. 

Tubercular  infection  is  oftentimes  most  puzzling  in  its  onset 
and  course,  giving  a  wide  variety  of  symptoms,  at  first  vague 
and  ill  defined,  and  only  later,  and  not  then  always,  showing 
distinct  evidence  of  localized  disease.  Each  case  gives  rise  to 
some  peculiar  features,  depending  upon  the  avenue  and  direction 
of  the  infection,  the  degree  of  resistance  in  the  tissues,  con- 
stitutional peculiarities,  and  the  like.  The  general  febrile  process 
thus  masks  the  local  disturbance,  which  may  escape  recognition 
altogether  or  be  only  shown  postmortem. 

In  infants  the  symptoms  are  often  merely  those  of  a  general 
wasting — a  marasmus  ;  the  subjects  are  pale,  thin,  slowly  losing 
weight,  and  finally  dying  of  exhaustion.  As  a  rule,  there  will  be 
recognized  a  fever,  possibly  much  higher  than  suspected  when  the 
thermometer  is  used,  but  seldom  regular  in  course  or  above  100° 
or  101°  F.  (37.7°  to  38.3°  C.).  Slight  pulmonary  signs  appear 
toward  the  end,  not  well  marked  or  in  themselves  significant ;  or 
these  may  become  pronounced,  especially  dyspnea  and  cough. 
Again,  the  symptoms  point  toward  lesions  of  the  digestive  tract, 
vomiting,  and  diarrhea  ;  and  these  may  be  due  to  the  constitu- 
tional disturbance  rather  than  local  infections  of  the  organs  dis- 
turbed. The  diagnosis  in  babies  under  a  year  old  can  only  be 
made  by  the  course  of  the  disease  and  the  knowledge  of  a  proba- 
ble tubercular  infection,  exposure  to  older  folks  who  suffer  from 
the  malady,  inheritance,  or  adequate  inference  from  collateral  con- 
ditions, infected  food,  etc.  In  older  children  the  symptoms  are 
those  of  a  continued  fever,  with  protracted  and  indefinite  symp- 
toms, each  one  insignificant,  but  collectively  convincing.  The 
subjects  are  generally  feeble,  ill  developed,  hypersensitive,  lack- 
ing in  vigor,  and  liable  to  catarrhal  or  dyspeptic  disturbances. 
Typhoid  fever  is  closely  simulated,  barring  the  characteristic  spots 
and  splenic  enlargement.  Always  there  are  the  wasting  and 
cachexia  ;  often  there  are  meningeal  symptoms. 


39 


6 10  THE    SPECIFIC    INFECTIOUS    DISEASES. 


TUBERCULOSIS  OF  THE  LUNGS. 

The  lungs  and  bronchi  are  most  commonly  affected  by  tuber- 
cular processes,  producing  pretty  much  all  varieties  of  pulmonary 
disease.  The  subjects  to  be  now  considered  are  those  states  of 
tubercular  involvement  where  the  most  conspicuous  disturbances 
are  observed  in  the  lungs,  producing  the  clinical  features  of  an 
acute  or  chronic  pulmonary  disease.  Two  groups  of  cases  may 
be  separated  :  the  rapidly  destructive  process,  acute  tuberculous 
bronchopneumonia,  and  a  slower  chronic  form,  accompanied  by 
ulceration,  called  chronic  pulmonary  tuberculosis. 

ACUTE  TUBERCULOUS  BRONCHOPNEUMONIA. 

Acute  tuberculous  bronchopneumonia  is  common  in  children 
from  the  sixth  month  to  the  fifth  year,  and  is  the  characteristic  and 
most  frequent  form  of  tuberculosis  in  early  life.  It  is  peculiarly 
liable  to  follow  the  acute  infectious  diseases,  especially  measles 
and  whooping-cough.  It  is  also  often  a  consequence  of  what- 
ever conditions,  acute  or  protracted,  have  profoundly  lowered  the 
general  health.  Inflammatory  disturbances  about  the  upper  air- 
passages  and  active  catarrhal  or  obstructive  troubles  seem  to  pre- 
dispose markedly  to  the  development  of  tuberculosis,  and  it  may 
be  the  terminal  process  in  persons  affected  by  local  tuberculous 
trouble  elsewhere.  The  pleura  is  usually  involved  also  ;  occa- 
sionally there  results  empyema.  Both  lungs  are  involved,  as  a 
rule,  in  different  degrees.  The  upper  lobe  of  the  lung  is  oftener 
affected  than  the  lower,  and  especially  that  part  near  the  root,  in 
the  region  of  the  bronchial  glands. 

Morbid  Anatomy. — The  essential  lesion  at  first  is  bron- 
chitis. The  tubercle  bacilli,  lodged  in  the  terminal  bronchioles, 
excite  a  proliferation  of  the  fixed  cells,  accompanied  by  the 
production  of  epithelioid  and  giant  cells,  which  frequently  con- 
tain the  bacilli.  This  epithelioid  element  acts  as  an  irritant, 
becomes  surrounded  by  leukocytes,  chiefly  polynuclear,  forming 
a  translucent  gray  mass,  the  tubercle  of  Laennec.  At  the  mar- 
gin of  the  tubercle  a  network  of  fibers  is  formed  from  the  connec- 
tive-tissue matrix.  The  tubercle  undergoes  changes  which  are 
in  the  nature  of  caseation  and  necrosis,  with  the  presence  of  the 
specific  bacilli  and  others  (Prudden),  as  the  streptococcus  and 
staphylococcus. 

Caseation. — The  bacilli  excite  a  coagulation-necrosis,  begin- 
ning in  the  center  of  the  tubercle  and  spreading  to  the  periphery, 
convert  the  tubercle  into  the  yellow,  cheesy  mass  so  common  in 


TUBERCULOSIS    OF    THE    LUNGS.  6ll 

tuberculosis.  At  this  stage  the  mass  may  undergo — (i)  soften- 
ing, (2)  encapsulation,  (3)  calcification,  or  (4)  sclerosis.  In  the 
first  the  softened  mass  may  break  into  a  bronchial  tube  and 
become  expectorated,  leaving  behind  an  excavation  with  ulcer- 
ating surfaces  ;  or,  (2)  being  encapsulated  by  the  overgrowth  of 
connective  tissue,  undergo  (3)  calcification,  or  (4)  necrosis  with 
increased  growth  of  fibrous  elements,  ultimately  ending  in  the 
conversion  of  the  tubercle  to  a  hard,  firm  structure.  In  some 
instances  a  simple  bronchopneumonia  precedes  the  tubercu- 
losis ;  especially  is  this  true  where  the  disturbance  follows  upon 
measles,  whooping-cough,  or  other  infectious  diseases. 

"  In  cases  of  tuberculosis  consecutive  to  bronchial  pneumonia 
we  find  the  lesions  of  two  sorts  :  Simple  inflammatory  non- 
tuberculous,  such  as  peribronchial  suppuration,  dilatation  of  the 
bronchi,  lesions  of  the  alveolar  epithelium,  and  peribronchial  and 
perialveolar  sclerosis  ;  then,  in  addition,  there  are  the  true  tuber- 
cular processes,  peribronchial  nodules,  tubercular  infiltration,  and 
caseous  areas  "  (Mosny,  quoted  by  Osier). 

Again,  sometimes  the  tuberculosis  is  established  before  the 
bronchial  pneumonia  sets  in,  especially  where  tuberculosis  is 
latent  in  the  individual,  and  a  bronchial  pneumonia  arises  from 
whatsoever  cause.  "  This  is,"  again  to  quote  from  Mosny,  "  a 
bronchopneumonia  dependent  upon  pneumococci  or  streptococci, 
invading  the  lung  already  the  seat  of  local  tuberculosis."  Once 
the  process  of  softening  is  established  in  children,  it  usually  pro- 
gresses until  the  life  of  the  patient  ceases.  The  bronchial  lymph- 
nodes  in  such  cases  will  be  found  tuberculous,  and  a  chain  of 
these  may  be  seen  to  lie  along  the  greater  bronchi.  Periods  of 
arrest  occur,  with  subsidence  of  the  physical  signs,  cell-organi- 
zation proceeding  to  produce  fibrous  walls,  acting  as  barriers  to 
the  advancing  process. 

Symptoms. — There  is  little  or  nothing  in  the  earlier  stages 
of  tubercular  bronchopneumonia  to  distinguish  it  from  the  simple 
form  :  the  physical  signs  are  the  same.  The  disturbances  of  the 
apex  are  of  no  importance  as  a  distinguishing  feature,  because  in 
children  the  tubercular  process  may  begin  at  the  base  or  center,  and 
the  closest  examination  of  the  lungs  may  reveal  little  or  nothing 
characteristic.  The  most  valuable  indication  of  the  special  nature 
of  the  trouble  is  in  the  course  and  progress  of  the  disease,  which 
exhibits  great  irregularity  in  the  temperature-range  and  marked 
evidences  of  rapid  loss  of  strength.  All  this  is  far  more  signifi- 
cant in  a  little  child  than  in  an  older  person,  in  whom  several 
factors  combine  to  form  such  a  picture.  Emaciation  soon  be- 
comes conspicuous,  sweats,  oftentimes  profuse,  accompany,  and 


6l2  THE   SPECIFIC    INFECTIOUS    DISEASES. 

the  gravity  of  the  disorder  becomes  obvious  from  many  things, 
producing  a  suggestive  syndrome.  Cough  may  or  may  not  be 
present. 

In  protracted  tubercular  bronchopneumonia  the  signs  of  con- 
solidation manifest  themselves,  involving,  it  may  be,  the  whole 
lobe.  This  proceeds  to  caseation,  softening,  and  cavity  formation. 
In  the  acute  cases  the  duration  is  about  a  month.  It  is  rarely 
possible  in  children  under  seven  to  secure  expectorated  matter 
in  which  to  exhibit  the  bacilli ;  and  yet  it  is  a  constant  matter 
for  surprise  how  extensive  tubercular  disease  may  be  present 
with  little  or  nothing  in  the  physical  signs  to  evidence  the  fact. 
Cavities  can  rarely  be  demonstrated,  though  small  ones  having 
ragged  or  irregular  walls  commonly  exist. 

CHRONIC  PULMONARY  TUBERCULOSIS. 

In  very  young  children  tuberculosis  shows  itself  in  the  lungs 
as  a  wide-spread  generalized  process,  involving  other  organs  as 
well,  or  as  a  bronchopneumonia.  In  older  children  of  seven  or 
eight  or  more  it  resembles  the  chronic  tuberculosis  of  adults. 
The  lesions  in  children  are  much  the  same  as  those  in  adults — 
miliary  tubercles,  peribronchial  nodules,  caseous  masses,  areas 
of  softening  and  of  fibroid  thickening,  and  cavities  of  various 
sizes.  The  parts  attacked  first  are  not  necessarily  near  the 
apex,  as  in  adults,  but  may  be  at  the  base  or  center.  The 
disease  spreads  directly  from  the  deeply  seated  glands,  either  in 
the  lung  itself  or  along  the  trachea  and  about  the  bronchi. 
Occasionally  considerable  areas  of  caseous  pneumonia  are  found  ; 
small  cavities  are  often  met,  but  large  ones  very  rarely.  A 
tubercular  bronchial  pneumonia  frequently  gives  origin,  through 
the  disturbance  of  the  smaller  bronchioles,  to  a  peribronchial 
alveolitis.  There  are  also  seen  caseous  masses,  gray  tubercles, 
infiltrations,  dense  fibroid  thickenings,  and  irregular  cavities  near 
the  roots  of  the  lungs  ;  one  or  both  bases  become  semisolid 
from  caseating  pneumonia,  or  similar  states  arise  at  the  apex. 
The  pleura  are  likewise  affected,  producing  empyema,  etc.  The 
liver,  kidneys,  and  spleen  exhibit  caseous  masses,  as  do  also 
the  mesenteric  glands,  and  ulcerations  form  in  the  intestines. 
Tubercles  are  found  in  the  peritoneum  and  meninges  of  the 
brain. 

Symptoms. — As  in  the  adult,  the  general  features  of  on- 
coming pulmonary  tuberculosis  in  a  child  are  those  of  marked 
pallor,  gastric  disturbance,  loss  of  flesh,  and  steadily  failing 
health.  The  phenomena  are  far  less  clear  and  distinctive  in 


TUBERCULOSIS    OF    THE    LUNGS.  613 

children.  Along  with  this  is  loss  of  appetite,  rarely  extreme. 
Slight  chilliness  may  indicate  fever,  and  malaria  or  typhoid  fever 
may  be  suspected.  Some  cases  follow  upon  recurring  bron- 
chitis along  with  nasopharyngeal  catarrh.  There  is  nearly  always 
a  hacking  cough,  at  first  dry  and  short,  by  and  by  looser, 
usually  in  the  morning,  sometimes  with  more  or  less  sputum, 
occurring  during,  the  day  or  at  night,  and  occasionally  par- 
oxysmal, like  whooping-cough.  Young  children  do  not  ex- 
pectorate ;  yet  if  over  eight  or  ten  years  of  age  they  may  do  so, 
and  the  sputum  is  merely  mucoid  at  first,  and  in  the  later  stages 
it  becomes  purulent.  Hemoptysis  is  rare  in  children.  Fever 
is  always  recognizable ;  this,  along  with  progressive  feebleness, 
acceleration  of  pulse,  and  a  slight,  regularly  recurring  cough, 
should  always  excite  solicitude.  The  fever  itself  in  the  earlier 
stages  is  remittent,  ranging  between  102°  and  104°  F.  (38.8° 
to  40°  C.).  When  the  disease  grows  more  extensive,  the  tem- 
perature has  the  quality  of  becoming  hectic — in  the  morning 
normal  or  subnormal,  while  in  the  evening  it  may  reach  104° 
or  105°  F.  (40°  to  40.5°  C.).  Chills  are  rare,  but  toward  the 
close  profuse  sweats  are  common.  Difficulty  of  breathing  may 
be  present  from  the  first,  due  in  part  to  the  fever  or  to  extensive 
bronchitis.  In  other  cases,  as  in  grown  people,  there  may  be 
little  or  no  dyspnea  and  yet  a  wide-spread  destruction  of  the  lung 
tissue  exist.  Tenderness  on  percussion  over  the  affected  areas  is 
often  observed  in  children.  The  digestive  organs  are  frequently 
involved,  and  not  seldom  a  persistent  diarrhea  indicates  tubercu- 
lous intestinal  ulceration.  Albuminuria  is  more  or  less  common 
in  the  later  stages.  General  anasarca  in  a  child  should  suggest 
tubercular  complications  involving  the  internal  organs. 

Physical  Signs. — Inspection. — The  chest  is  usually  long  and 
flat ;  the  affected  side  may  show  limited  movements,  with 
prominence  of  the  clavicle,  or  in  chronic  cases  flattening  with 
depression  of  the  shoulder.  On  palpation  there  may  be  dis- 
covered limited  expansion  and  increased  vocal  fremitus.  Per- 
cussion.— There  is  little  or  no  change  in  the  percussion-note  in 
the  earlier  conditions,  except,  perhaps,  if  one  apex  is  considerably 
involved  ;  then  there  is  dullness  above  and  below  the  clavicle  ; 
supraspinous  fossal  flatness  is  rare.  The  cracked-pot  sound  is  of 
no  value  in  children.  Auscultation  may  exhibit  the  various  sounds 
of  bronchial  catarrh,  alteration  in  respiratory  sounds,  and  rales, 
moist  and  piping.  The  sounds  heard  in  the  chest  are  by  no 
means  reliable  guides  as  to  the  really  grave  features.  The  shal- 
lowness  of  the  infantile  chest  makes  it  most  difficult  to  estimate 
fairly  differences  in  resonance.  In  children  the  course  of  chronic 


6 14  THE    SPECIFIC    INFECTIOUS    DISEASES. 

tuberculosis  of  the  lungs  is  much  more  rapid  than  in  adults,  and 
they  rarely  survive  longer  than  a  year.  Occasional  phases  of  im- 
provement may  be  seen,  along  with  periods  of  high  fever  and  rapid 
loss  of  strength.  In  rare  instances  chronic  tubercular  changes 
merge  into  fibroid  conditions,  and  a  fair  measure  of  health  may 
be  regained,  enabling  the  child  to  live  a  number  of  years.  Club- 
fingers  are  exhibited  under  these  conditions,  a  sign  merely  of 
chronic  degenerative  change.  Suspicion  of  tuberculosis  should 
always  be  aroused  whenever  progressive  emaciation  takes  place 
in  a  child  with  cough  and  hectic  fever.  Tuberculous  broncho- 
pneumonia  is  the  condition  found  early,  but  the  progressive 
character  of  the  lesion  may  often  be  traced.  Every  effort  should 
be  made  to  secure  some  portion  of  sputum,  which  will  help  to 
clear  up  the  diagnosis.  The  recovery  from  tuberculous  states 
in  children  is  comparatively  rare  if  once  hectic  fever  is  estab- 
lished. Tuberculosis  may  attack  the  pleura,  usually  secondarily 
to  existing  disease  in  the  lung.  The  pericardium  is  also  occa- 
sionally involved ;  this  is  usually  associated  with  tuberculosis  of 
the  mediastinal  and  bronchial  glands.  The  kidneys  and  intes- 
tines also  are  not  seldom  found  infected,  producing  albuminuria 
and  disorders  of  digestion,  persistent  and  recurrent. 

Diagnosis. — Hectic  fever,  dry  cough,  persistent  catarrh  of  the 
respiratory  tract,  diarrhea,  emaciation,  and  evidences  of  consoli- 
dation are  probable  signs  of  chronic  tuberculosis  of  the  lungs. 
The  discovery  of  bacilli  in  the  sputum  is  the  only  positive  diag- 
nostic sign  of  the  disease.  Trudeau  condemns  the  waiting  for 
marked  physical  signs  or  a  clinical  picture,  and  urges  the  use 
of  the  tuberculin  test,  which  he  declares,  is  the  most  searching 
and  delicate  means  of  detecting  early  tubercular  disease.  It  is 
not  dangerous  in  incipient  cases,  and  no  harm  results  from  small 
graded  doses  at  two  or  three  varying  intervals. 

Prognosis. — The  ultimate  outlook  is  distinctly  unfavorable, 
though  the  disease  is  not  incurable.  A  family  history  of  con- 
sumption adds  much  to  the  gravity  of  the  outlook,  showing  a 
lessened  power  of  resistance  to  the  toxins.  When  cases  are  seen 
early  and  placed  under  proper  treatment,  recovery  may  take 
place.  Prognosis  is  bad  when  hectic  is  established,  appetite  poor, 
and  the  stomach  of  defective  competency. 

Treatment. — Preventive. — Knowing  that  tuberculosis  is  an 
infectious  disease  and  that  children  are  exceedingly  susceptible, 
prophylactic  measures  should  be  instituted,  and  their  observ- 
ance insisted  on  both  by  the  patients  and  by  the  members  of 
the  household.  The  consumptive  adult  who  comes  in  contact 
with  children  should  not  spit  promiscuously  about  the  house, 


TUBERCULOSIS  OF  THE  LUNGS.  615 

or  in  the  cars  or  public  conveyances.  Sputa  of  consumptives 
should  be  received  in  a  suitable  vessel,  containing  antiseptic  solu- 
tion, and  afterward  destroyed.  Pieces  of  linen  can  be  used  for 
this  purpose  and  subsequently  burned.  The  healthy  should  not 
sleep  in  rooms  occupied  by  those  suffering  from  this  malady. 
Kissing  is  to  be  positively  prohibited.  Cattle  should  be  rigidly 
inspected,  and  all  meat  and  milk  of  tubercular  cows  declared 
unmarketable.  A  consumptive  mother  should  not  nurse  her 
child. 

The  treatment  of  all  varieties  of  tuberculosis  in  man  re- 
solves itself  into  one  plain  proposition,  and  that  is  the  main- 
tenance of  nutritive  vigor.  Along  with  this  is  the  whole  ques- 
tion of  the  powers  of  resistance  or  immunity  which  may  be 
natural  or  acquired.  Whatever  makes  for  resisting  power  makes 
for  recovery.  Drugs  which  are  useful  in  reinforcing  the  powers 
of  resistance  for  the  patient  by  regulating  and  maintaining  the 
activities  of  the  various  bodily  organs  are  strychnin,  digitalis, 
animal  and  vegetable  digestive  ferments,  mercury,  nitroglycerin, 
mineral  and  fruit  acids,  vegetable  tonics,  iron,  bismuth,  charcoal, 
and  diffusible  stimulants. 

Strychnin  is  a  most  valuable  remedy.  It  probably  acts  by 
overcoming  in  some  way  the  inhibition  which  the  irritated  nerve- 
ends  of  the  vagus  exercise  upon  nutritional  processes.  Digi- 
talis is  a  useful  remedy  in  the  treatment  of  tuberculosis,  but  it 
should  be  used  only  when  there  is  positive  indication  for  it. 
Incompetence  in  the  circulatory  system,  whether  in  the  blood- 
vessels or  in  the  heart,  calls  for  digitalis  or  some  of  its  derivatives. 

The  diffusible  stimulants  are  of  great  efficacy  in  emergencies, 
such  as  depressed  states  of  the  nervous  system  or  circulation. 
Aromatic  ammonia  used  freely  will  do  much  good  ;  also  good 
brandy  or  whisky  or  the  old,  heavy-bodied  wines,  as  port  and 
Madeira. 

Of  the  drugs  which  aid  immunity  directly,  iodin  is  rated  the 
highest  by  some.  Flick  prefers  europhen  and  olive  oil  by  inunc- 
tion, and  claims  that  iodin  used  in  this  way  is  practically  a  specific 
in  early  phthisis.  To  aid  glandular  activities  the  mercury  salts 
are  of  much  utility.  In  states  of  biliousness  a  well-directed  dose 
of  calomel,  ipecac,  and  rhubarb  will  help  back  upon  a  plane  of 
vigor  what  seem  oftentimes  alarming  conditions  of  depression, 
physical  and  mental.  For  hemoptysis  nitroglycerin  is  the  main 
reliance. 

It  is  a  happy  circumstance  that  this  most  wide-spread  and 
prevalent  disease  is  sometimes  spontaneously,  and  oftentimes 
entirely,  to  be  checked  by  suitable  measures  adapted  to  each 


6l6  THE    SPECIFIC    INFECTIOUS    DISEASES. 

case.  The  measures  to  be  employed  are,  first,  to  live  in  the 
purest  possible  air  and  become  inured  to  the  changes  of  the 
weather  ;  to  get  as  much  as  possible  of  dry  air  and  sunshine. 
The  next  thing  is  to  secure  perfectly  good,  abundant,  and  well- 
prepared  food,  and  to  digest  and  assimilate  it.  The  staple  diet 
should  be  nitrogen  and  fat.  The  starch  foods  are  highly  impor- 
tant, and  if  not  well  tolerated,  they  give  trouble.  The  use  of 
diastatic  ferments  will  relieve  this.  Lastly,  there  is  a  series  of 
nutrient  tonics  which  have  enjoyed  the  confidence  of  medical 
men  since  the  earliest  ages,  at  the  head  of  which  list  stands 
cod-liver  oil,  to  be  taken  one-half  to  three-quarters  of  an  hour 
after  meals,  or  when  and  how  proves  best  suited  to  the 
stomach. 

Special  treatment  for  the  tubercular  process  has  never  been 
crowned  with  any  very  remarkable  success.  The  brilliant  possi- 
bilities of  Koch's  tuberculin  have  never  yet  been  realized,  but 
hope  along  those  lines  has  never  been  altogether  abandoned. 
Internally  creasote,  and  its  derivative  guaiacol,  now  enjoy  the 
confidence  of  the  medical  faculty.  From  its  use  excellent  results 
have  been  obtained.  The  use  of  nucleins,  too,  by  reinforcing 
leukocytosis,  holds  out  glittering  promises.  There  are  many 
preparations  most  helpful,  of  which  phospho-albumin  is  a  type 
and  the  one  which  has  given  us  the  most  satisfaction. 

The  influence  of  creasote  seems  to  be  that  of  a  general  nutri- 
tive stimulant,  lessening  the  fever,  promoting  tissue  elaboration 
and  digestive  vigor,  and  in  other  ways,  not  clearly  shown,  pro- 
ducing favorable  results.  It  seems  in  some  way  to  combat  the 
toxins  of  mixed  infections,  in  which  pus-producing  germs  take 
part,  and  which  constitute  perhaps  the  most  serious  condition 
into  which  a  tuberculous  patient  can  fall.  This  is  manifested  by 
chills,  fever,  sweats,  distressing  cough,  and  profuse  expectoration. 
Creasote  in  large,  well-sustained  doses  will  greatly  reduce  suffer- 
ing and  aid  recovery.  The  dose  fora  young  child  is  from  y2  to 
one  minim,  steadily  increased  to  as  much  as  it  will  bear,  the  index 
of  endurance  being  the  tolerance  of  the  stomach.  A  convenient 
method  is  to  put  creasote  in  capsules  or  pearls,  which  children 
can  readily  be  taught  to  swallow,  or  mix  it  with  some  simple 
elixir,  of  which  the  very  agreeable  fluid  preparations  of  pepsin 
and  pancreatin  now  on  the  market  serve  as  excellent  menstrua.* 

*  Flick  states  that  the  best  way  to  administer  creasote  is  in  large  drafts  of  hot  water 
some  time  before  meals.  For  children  who  refuse  this  highly  aromatic  offensive  sub- 
stance there  are  combinations  almost  tasteless  which  have  served  us  well,  as  benzosol, 
etc.  The  beneficial  effect  of  creasote  may  be  due  (t)  to  a  bactericidal  effect  of  crea- 
sote against  the  bacilli  which  are  associated  with  the  tubercle  bacillus — streptococci, 


TUBERCULOSIS    OF    THE    LUNGS. 

It  is  usefully  administered  in  the  form  of  an  inhalation.  Guaiacol 
is  well  tolerated  dropped  on  a  lump  of  sugar  or  into  an  elixir. 
None  of  these  highly  volatile  substances  should  be  made  up  in  a 
mixture  of  a  perishable  nature  and  allowed  to  stand.  They  are 
better  dropped  into  the  menstruum  immediately  before  using. 
Hypodermically,  guaiacol  is  used  along  with  sterilized  olive  oil 
in  a  5  per  cent,  solution.  Other  balsamic  substances  have  been 
used  by  various  authorities  with  good  effect. 

It  is  an  exceedingly  nice  point  to  choose  a  suitable  climate  for 
the  sufferers  from  the  more  active  forms  of  tuberculosis,  and 
while  the  more  distant  resorts  difficult  of  access  enjoy  the  most 
classic  reputations,  nevertheless  there  are  places  comparatively 
near  by  each  one's  home  where  the  local  conditions  are  all 
that  are  actually  needed,  provided  great  care  is  exercised  in 
the  selection  of  the  house  site.  For  instance,  there  are  to 
be  found  near  most  of  our  cities  sheltered  valleys,  especially 
upon  hillsides  looking  to  the  south,  surrounded  preferably 
or  fringed  by  evergreens,  where  a  close  observer  will  note 
a  quality  in  the  growing  plants  which  testifies  to  salubrity. 
The  building  of  a  little  cabin  here  will  oftentimes  afford 
very  nearly  all  the  advantages  to  be  had  in  remote  and  well- 
known  health  resorts,  with  few  of  their  disadvantages.  It  is  not 
necessary,  nor  is  it  even  desirable,  for  children  to  be  dragged 
to  the  ends  of  the  earth,  at  great  expense  and  infinite  trouble 
and  sacrifices  on  the  part  of  their  parents,  when  all  the  essential 
conditions  can  be  partly  found  and  partly  provided  at  sma.ll 
expense  and  under  intelligent  guidance  be  procured  somewhere 
near  their  homes.  The  one  thing  essential  to  those  predisposed 
to  tuberculosis  is  a  life  in  the  open  air  during  the  best  part 
of  their  waking  hours.  The  needful  conditions  can  be  found  in 
an  acre  or  less  of  ground  through  which  they  can  range  and 
play  at  will.  In  suitable  weather  they  may  venture  further 
abroad  and  thus  enjoy  a  needful  variety.  The  treatment  of  more 
acute  tubercular  conditions,  as  where  fever  has  set  in,  can  be 
accomplished  far  better  within  easy  reach  of  home  than  in  the 
more  remote  health  resorts.  Here  the  open  air  is  most  essential, 
also,  with  opportunities  for  swift  retreat  to  a  solarium,  or  a  large, 
well-warmed  room,  when  the  weather  changes.  The  fever  itself 
is  most  obstinate  and  serious.  Local  cold,  as  by  sponging,  is 

pneumobacilli,  etc. ;  (2)  stimulation  of  the  metabolism,  which  increases  and  strengthens 
phagocytosis ;  (3)  a  chemic  effect  of  the  phenol  group,  which  leads  to  a  neutralization 
of  the  toxins.  The  chemic  action  of  creasote  increases  with  the  quantity.  Creasote 
is  to  be  used  only  in  noncachectic  tuberculous  patients,  in  the  first  and  second  stages 
(Savoire). 


6l8  THE    SPECIFIC    INFECTIOUS    DISEASES. 

the  best  means  of  reducing  this,  as  it  serves  the  additional  pur- 
pose of  acting  as  a  powerful  vasomotor  tonic. 

Among  the  mixed  infections  the  most  serious  are  the  pus- 
producing  germs,  with  the  phenomena  of  fever,  sweats,  and  dis- 
tressing cough.  For  this  the  great  remedy  is  creasote,  in  full 
increasing  systematic  doses.  For  hectic  and  sweating,  astringents 
to  the  skin — aromatic  vinegar  or  aromatic  sulphuric  acid  is  useful 
applied  upon  the  surface.  Internally  this  last  may  be  given 
along  with  nux  vomica.  Picrotoxin  checks  sweating  admirably  in 
small  doses,  gradually  increased  ;  so  does  the  hydrobromate  of 
hyoscin.  Agaricin  and  zinc  oxid  in  pill  form  have  been  highly 
recommended  to  check  sweating.  For  the  relief  of  cough  the 
various  preparations  of  opium  have  never  yet  been  surpassed. 
The  old-fashioned  paregoric  is  here  still  supreme,  or  McMunn's 
elixir  or  the  derivatives  of  opium,  especially  codein  or  morphin. 
External  applications  are  oftentimes  most  comforting  :  occasion- 
ally poultices,  for  their  heat  and  moisture,  or  medicated  in  vari- 
ous ways — the  addition  of  laudanum  or  a  poultice  made  of  hops. 
Tubercular  diarrhea  is  a  serious  symptom,  requiring  the  prompt 
use  of  astringents,  as  lead,  tannin,  gallic  acid,  sulphuric  acid, 
and  the  like.  Various  aids  to  digestion  are  usually  indicated, 
the  mineral  acids,  the  vegetable  bitters,  pepsin,  pancreatin,  caroid, 
peptenzyme,  protonuclein,  or  the  compound  nucleins  ;  the  syrup 
of  phospho-albumin  is  of  great  value.  A  well-prepared  form  of 
cod-liver  oil,  if  it  is  made  from  the  fresh  livers  and  is  free  from 
rancidity,  such  as  Stone's  Cod  Oil,  is  a  great  help  in  many  forms 
of  nutritional  disturbance.  This  may  be  given  in  capsule,  small 
amounts  of  a  good  article  sufficing  ;  or  a  sound  oil  may  be  put 
in  the  form  of  an  emulsion  at  home,  with  a  fresh  raw  egg  and  a 
small  quantity  of  glycerin  or  honey,  with  the  addition,  it  may 
be,  of  Jamaica  rum  or  other  spirits,  the  whole  shaken  together  in 
a  stone  or  amber-tinted  bottle  to  defend  it  from  the  light,  and 
used  up  in  a  few  days. 

In  dealing  with  tubercular  conditions  prevention  is  much  the 
most  important  part  of  treatment ;  this  involves  not  only  pre- 
venting the  sources  of  contamination  reaching  the  individuals, 
which  is  to  be. done  by  zealously  guarding  them  from  all  sources 
of  infection,  but  whenever  tubercular  glands  are  recognized,  these 
should  be  promptly  and  thoroughly  removed  by  a  surgeon. 
In  children  so  predisposed  the  utmost  pains  should  be  taken  to 
rear  them  hygienically,  and  particularly  to  guard  against  and 
cure  all  catarrhal  affections.  The  children  should  be  especially 
encouraged  to  take  and  assimilate  fat,  and  be  guarded  during 
their  convalescence  from  contagious  diseases. 


TYPHOID    FEVER.  619 


TYPHOID    FEVER. 
Synonym. — ENTERIC  FEVER. 

Typhoid  or  enteric  fever  is  an  acute  infectious  disease  due  to  a 
specific  bacillus  (Eberth).  In  children  it  is  in  most  essential  re- 
spects similar  to  the  same  disease  in  adults,  although  in  some 
clinical  features  there  are  differences  which  must  be  considered. 
Moreover,  typhoid  fever  in  recent  years  differs  in  many  particu- 
lars from  those  forms  observed  and  described  in  the  past.  For 
a  long  time  it  was  thought  that  infants  and  young  children  were 
immune  to  this  disease ;  but  although  rarely,  yet  we  do  find  it 
occurring  in  children  only  a  few  months  old,  but  in  these  instances 
it  is  almost  inevitably  acquired  from  a  nursing  mother  who  is  her- 
self infected.  We  have,  ourselves,  recorded  cases  of  this  disease 
in  babies  of  five  and  eight  months  of  age. 

Typhoid  fever  may  be  described  as  an  infectious  disease,  due 
probably  to  more  than  one  cause,  the  chief  of  which  is  the 
bacillus  of  Eberth,  and  is  characterized  by  a  continued  fever 
lasting  from  one  to  three  weeks,  and  a  peculiar  eruption  of  small 
rose-colored  spots  which  disappear  on  pressure  and  appear  in 
successive  crops.  Along  with  this  are  certain  characteristic  le- 
sions in  the  ileum,  accompanied  by  gastro-intestinal  catarrh.  The 
prevalence  of  this  disease  among  children  is  presumably  much 
more  extensive  than  we  can  ascertain,  as  many  cases  of  mild  and 
ill-defined  character  probably  are  never  recognized  as  such. 
Especially  is  this  true  among  the  poor. 

Causes. — The  causes  of  typhoid  fever  may  be  said  to  be  pre- 
disposing, specific,  and  contributory.  Undoubtedly  there  are 
certain  individuals  who  are  more  liable  to  this  disorder  than 
others,  and  these  vary  in  their  susceptibility.  Many  collateral 
causes  influence  susceptibility,  of  which  the  season  of  the  year  is 
one  of  the  most  pronounced ;  so  much  so  that  it  has  received 
the  name  of  "  autumnal  fever."  Age  also  is  an  important  factor, 
by  far  the  largest  number  of  cases  occurring  in  later  childhood, 
and  most  in  early  adult  life,  and  less  both  above  and  below  the 
ages  of  fourteen  and  twenty-five.  There  is  little  influence  ex- 
erted by  sex,  climate,  or  mode  of  life.  Atmospheric  conditions 
affect  the  prevalence  of  the  disease,  dry  heat  seeming  to  favor, 
and  cold  and  damp  rather  to  check,  its  prevalence.  The  invasion 
is  usually  by  the  mouth  and  stomach.  A  degree  of  immunity 
seems  to  be  acquired  by  repeated  exposures  to  infection. 

The  bacillus  of  Eberth  is  constantly  found  in  those  dying  of 
typhoid  fever,  but  it  is  not  proved  that  this  alone  is  the  exciting 


62O  THE   SPECIFIC    INFECTIOUS    DISEASES. 

cause  of  the  disease.  A  number  of  causes  may  be  described  as 
contributory  or  supplemental,  which  were  for  a  long  time  regarded 
as  efficient.  These  are  sewer-gases,  evil  odors  emanating  from 
various  sources,  defective  ventilation,  and  the  like.  It  is  pretty 
well  determined  that  these  in  themselves  are  incompetent  to  pro- 
duce infection.  They  may  possibly  convey  small  amounts  of 
poison  to  the  air-passages,  whence  they  become  entangled  in 
the  mucus  and  are  swallowed,  but  this  is  unlikely.  By  acting 
as  profound  depressants  they  may  create  or  aggravate  a  condition 
of  susceptibility,  and  they  certainly  do  so  depress  the  vitality  as 
to  diminish  the  powers  of  resistance.  Enteric  fever  is,  strictly 
speaking,  contagious,  but  it  is  very  rare  to  learn  of  instances  of 
direct  contagion.  Undoubtedly,  in  the  homes  of  the  poor, 
where  one  member  of  the  family  is  infected  others  acquire  the 
disease.  Here  two  causes  are  at  work  :  a  similarity  of  infective 
source  and  direct  or  immediate  contagion.  Nurses  in  hospitals 
have  acquired  the  disease,  presumably  from  handling  the  dejecta 
— the  feces  and  urine — or  by  food  thus  contaminated,  and  the 
soiled  clothing.  Thus  bacilli  may  be  passed  by  accident  into  the 
mouth,  and  thence  proceed  to  work  their  mischief  in  the  ordinary 
way.  Flies  or  other  insects  may  be  the  obscure  source  of  con- 
veyance. 

Immediate  contagion  is  by  far  the  most  common.  In  most 
instances  the  poison  is  conveyed  by  drinking-water.  Various 
articles  of  food,  particularly  infected  milk,  are  equally  responsible, 
but  this  again  may  be  directly  or  indirectly  through  water  con- 
veyance. The  bacilli  retain  their  vitality  for  weeks  in  water,  but 
probably  do  not  increase  therein  to  any  extent.  They  retain 
their  virility  for  a  month  or  more,  even  when  dried.  They 
may  live  in  ice  for  months.  In  the  soil  they  remain  vigorous, 
and  also  increase,  and  so  in  milk  ;  they  are  readily  cultivated 
without  changing  their  appearance.  "  Once  in  the  intestinal 
canal,  the  typhoid  germs  probably  do  not,  like  the  cholera  bacilli, 
increase  in  the  secretions,  but  penetrate  the  epithelial  lining  and 
reach  the  lymphoid  tissue,  upon  which  they  exert  their  specific 
action,  causing  a  cell  proliferation  greatly  in  excess  of  the  physio- 
logic process  "  (Osier).  When  introduced  into  the  human  body, 
the  bacillus  is  capable,  under  favorable  circumstances,  of  indefi- 
nitely reproducing  itself  and  retaining  its  activity.  It  tends  to 
collect  in  certain  organs,  especially  in  the  liver  and  spleen. 
"  The  bacilli  penetrate  into  the  solitary  follicles  and  Peyer's 
patches,  and  there  multiply  and  form  colonies.  From  these 
colonies  they  migrate  by  way  of  the  lymphatic  vessels  to  the 
mesenteric  ganglia,  and  by  way  of  the  radicles  of  the  superior 


TYPHOID    FEVER.  621 

mesenteric  veins  to  the  liver,  to  be  finally  distributed  by  the 
blood  current  to  the  spleen  and  other  organs"  (Wilson).  They 
are  excreted  by  the  kidneys,  as  well  as  by  the  bowels.  Incubation 
varies  enormously  and  is  variously  stated  to  be  from  two  days 
to  three  weeks. 

Morbid  Anatomy  and  Pathology. — The  postmortem  find- 
ings in  typhoid  fever  are  thoroughly  characteristic  and  quite  in- 
dependent of  symptoms.  The  febrile  movement  and  various  items 
making  up  the  clinical  picture  of  enteric  fever  are  quite  independ- 
ent of  these  lesions,  and  are  due  to  the  action  of  specific  poisons 
or  toxins.  The  anatomic  lesions,  as  pointed  out  by  Wilson,  fall 
naturally  into  two  groups,  the  first  including  those  which  arise 
from  the  local  action  of  the  bacilli  and  their  concentrated  pto- 
mains,  and  affect  changes  chiefly  in  the  lymphatic  system  and 
the  intestinal  canal.  The  second  group  includes  lesions  due  to 
long-continued  constitutional  infection,  consisting  of  degenera- 
tive changes  in  various  tissues  and  organs,  particularly  the  liver, 
kidneys,  voluntary  muscles,  heart,  salivary  glands,  and  pancreas  ; 
less  conspicuously  in  the  nervous  system.  These  last  are  least 
extensive  and  conspicuous  in  children,  nor  have  they  been  so  care- 
fully studied.  The  most  conspicuous  lesions  are  seen  in  the  diges- 
tive tract,  though  here  the  destructive  changes  are  far  less  than  in 
adults.  Ulceration,  while  not  infrequent,  is  much  rarer  than  in 
adults  ;  the  process  is  more  of  a  hyperplastic  change.  Oftentimes 
there  is  only  moderate  redness  and  swelling  of  Peyer's  patches, 
solitary  follicles,  and  mesenteric  lymph-nodes,  lesions  frequent 
in  cases  of  simple  diarrhea.  We  now  know  that  typhoid  fever 
can  exist  without  any  intestinal  lesions  whatever.  Sometimes 
the  disease  occurs  in  the  nature  of  a  septicemia,  or  the  process 
may  be  localized  in  the  pelvis  of  a  kidney,  in  the  gall-bladder, 
in  the  periosteum  of  some  bone,  or  in  other  tissues.  Park  speaks 
of  the  great  importance  of  recognizing  the  nature  of  the  disease 
in  these  irregular  instances.  Sometimes  the  pharynx  exhibits 
diphtheric  exudation  ;  the  esophagus  is  at  times  ulcerated,  and 
the  mucous  membrane  of  the  stomach  inflamed.  The  constant 
and  characteristic  lesion  is  of  the  solitary  and  agminated  glands 
in  the  lower  part  of  the  ileum,  evidenced  at  first  by  swelling  and 
hyperemia,  attaining  their  maximum  about  the  end  of  the  first 
week,  and  then  undergoing  resolution  without  ulceration.  If 
the  lymphatic  infiltration  continues,  in  another  week  necrosis 
results  and  an  ulcer  is  formed,  which  in  children  has  a  tendency 
to  heal.  If  the  ulceration  becomes  deeper,  it  may  involve  the 
whole  of  a  Peyer's  patch,  and,  attacking  the  walls  of  an  artery, 
produce  hemorrhage,  or  the  wall  of  the  intestine  may  be  perfor- 


622  THE   SPECIFIC    INFECTIOUS    DISEASES. 

ated  unless  protected  by  a  plastic  lymph.  Hyperplasia  of  the 
lymph-follicles,  in  children  especially,  occurs  in  other  diseases 
involving  the  intestines,  as  in  measles,  diphtheria,  and  scarlet 
fever.  In  children  the  swelling  of  Peyer's  patches  is  seen  earlier 
than  in  adults,  and  most  often  near  the  ileocecal  valve,  but  is 
also  found  higher  up  in  the  small  intestines.  Under  six  or  seven 
years  of  age  the  process  is  much  less  severe.  Hemorrhage  is 
also  comparatively  rare,  and  seldom  occurs  earlier  than  the  third 
week.  The  spleen  is  usually  found  swollen  and  in  all  cases 
more  or  less  involved,  but  distinctly  less  so  than  in  adults. 
Various  other  changes  incident  upon  intense  toxic  infection  and 
protracted  fever  are  seen  in  other  organs,  such  as  a  hyperemic 
state  of  the  liver,  diminished  amount  of  bile,  degenerative 
changes  in  the  kidneys,  with  or  without  albuminuria.  The  heart 
is  liable  to  involvement,  and  while  endocarditis  and  pericarditis 
are  rare,  the  myocardium  is  liable  to  become  relaxed  and  flabby 
or  may  undergo  fatty  degeneration.  The  voluntary  muscles 
suuer  sometimes  profoundly.  The  lungs  exhibit  characteristic 
changes  resulting  from  enfeebled  circulation  and  obtunded  nerves. 
Hypostasis  is  common,  also  pulmonary  edema.  Lobar  pneumo- 
nia not  only  occurs,  but  sometimes  appears  at  the  beginning. 

Symptoms. — The  course  of  typhoid  fever  in  children,  while 
less  severe,  is  very  similar  in  its  more  conspicuous  features  to  that 
of  adults.  It  is  of  shorter  duration,  with  the  nervous  phenomena 
at  times  overshadowing  those  of  the  intestines.  This  is  true  of 
by  far  the  larger  number  of  cases  as  seen  by  the  average 
observer.  We  are  more  liable  to  meet  with  and  recognize 
instances  of  the  disease  which  pursues  the  ordinary  course,  as 
seen  in  older  folk.  There  are  those  who  do  not  agree  with  this 
view,  but  regard  the  disease  as  manifesting  itself  differently  in 
children.  The  successive  periods  of  development  are  not  so 
clearly  defined.  Very  many  less  well-marked  cases  escape 
attention,  unless  it  be  very  sharply  aroused,  and  this  frequently 
happens,  the  cases  presenting  themselves  only  during  a  relapse 
or  in  the  stage  of  subsidence.  In  young  children  the  disease 
is  more  apt  to  begin  with  a  sudden  onset,  with  many  of  the 
symptoms  fully  developed.  The  febrile  process  is  generally 
less  severe,  although  the  temperature-range  may  be  equally 
high.  The  symptoms  rarely  reach  the  same  severity  as  among 
adults ;  the  complications  are  fewer,  and  the  sequelae  less 
marked.  We  recall  no  less  than  twenty  cases  of  typhoid  fever 
in  children  ranging  from  five  to  twelve,  occurring  in  the  last  five 
years,  which  pursued  a  perfectly  typical  course,  with  recovery. 
We  can  also  recall  probably  twice  that  number  of  children 


TYPHOID    FEVER.  623 

applying  at  the  out-patient  department  of  the  Children's  and  the 
Polyclinic  Hospital  service  that  we  regarded  as  probably  suffer- 
ing from  typhoid,  but  who  disappeared  from  view  after  but  one 
interview  ;  the  most  of  them  got  well,  as  we  have  reason  to 
know.  Had  there  been  increased  seventy  or  complications,  the 
greater  part  of  these  would  have  again  applied  for  advice.  They 
were  subsequently  seen  for  slight  ailments  in  no  way  connected 
with  this  disease.  Certain  other  cases  gravely  suspected  of  being 
aberrant  typhoid  presented  themselves  regularly  until  quite  well. 
Prodromes,  except  in  severe  instances,  are  usually  of  the  vaguest, 
and  these  are  generally  connected  with  the  digestive  tract. 
Nosebleed  is  rare  in  children,  and  so  is  diarrhea,  and  headache  is 
seldom  complained  of.  The  temperature,  when  typical,  rises 
slowly  for  from  two  to  seven  days,  remitting  a  degree  or  two,  or 
even  three,  in  the  second  week,  declining  steadily  in  the  third 
week,  at  the  end  of  \vhich  the  normal  is  reached  ;  it  may  even 
appear  to  fall  by  crisis  in  some  cases.  It  may  shoot  up  abruptly 
to  102°  or  105°  F.  (38.8°  to  40.5°  C.)  at  once,  but  later  run  the 
regular  course  of  gradual  rise  and  fall,  morning  remissions  with 
evening  exacerbations,  oftentimes  by  no  means  so  marked  as 
with  adults,  and  may  even  be  absent.  The  pulse  is  frequently 
found  to  be  slower  than  should  be  expected  from  the  degree  of 
temperature,  as  in  older  folk. 

In  young  children  the  febrile  progress  is  often  only  from  eight 
to  fourteen  (8  to  14)  days  (Morse),  the  average  course  under  ten 
years  is  19.3  days  ;  ten  to  fifteen  years,  22.6  days  ;  after  the  age 
of  ten  this  course  is  much  like  that  of  adults.  The  maximum 
fever  in  mild  cases  is  103°  to  104°  F.  (39.4°  to  40°  C.)  ;  in 
severe  cases  it  may  reach  105°  to  106°  F.  (40.5°  to  41.1°  C.) 
— higher  than  in  adult  cases  of  similar  severity. 

Typhoid  fever  is  perhaps  the  only  disease  in  which  the  tem- 
perature runs  higher  in  older  than  in  younger  children  (Holt). 
Subnormality  obtains  at  the  end  of  the  course,  and  rises  are  due 
to  intestinal  or  other  disturbances.  The  tongue  is  not  so  char- 
acteristic as  in  adults,  and  may  be  quite  clean.  There  is  a 
peculiar  thick,  heavy  coating,  with  the  tip  and  margins  free,  with 
sometimes  a  V-shaped  oval  red  place  in  the  center,  which  is 
claimed  to  be  pathognomonic  ;  but  the  absence  of  striking  lingual 
features  is  in  no  way  reassuring.  There  is  usually  loss  of  appe- 
tite from  the  beginning,  but  food  will  be  accepted,  nausea  being 
rare  and  vomiting  more  so.  The  mouth,  tonsils,  and  naso- 
pharynx usually  appear  inflamed,  and  may  exhibit  a  fairly  severe 
catarrh,  especially  in  those  of  impaired  nutrition.  The  bowels 
are  rarely  loose,  at  least  it  seems  so  nowadays,  constipation 


624  THE    SPECIFIC    INFECTIOUS    DISEASES. 

being  much  more  frequent  than  was  formerly  taught.  It  is 
present  in  about  half  the  cases  (Holt ;  Morse  says  one-third). 
Constipation  at  the  beginning  may  be  succeeded  by  diarrhea 
later  in  the  attack.  The  gurgling  and  pain  in  the  right  iliac 
region  mean  comparatively  little  in  children,  because  they  can 
be  so  constantly  elicited  even  in  the  well.  The  spleen  is  always 
enlarged,  though  not  always  palpable  (about  1 5  per  cent.),  and 
is  quite  a  characteristic  and  early  sign  of  typhoid  fever  in  chil- 
dren ;  it  is  also  often  tender.  The  size  is  an  index  of  prognosis 
as  well  as  of  diagnosis  ;  while  it  persists,  the  disease  is  not 
ended.  The  eruption,  which  is  a  very  common  symptom, — 
60  per  cent,  of  cases, — is  noticed  early  in  the  course  of  the 
disease,  and  consists  of  pale-red,  "  rose-colored,"  flat,  slightly 
elevated  spots  which,  on  being  pressed  with  the  finger,  disappear 
for  a  moment  and  reappear  somewhat  slowly.  They  are  usually 
few  and  scattered,  but  occasionally  very  abundant ;  generally 
seen  on  the  abdomen,  but  if  in  large  numbers,  they  may  also  be 
found  on  other  parts  of  the  body.  They  are  found  on  the  back, 
in  the  region  of  the  shoulders,  at  times,  when  absent  elsewhere. 
The  abdomen  is  usually  more  or  less  distended,  and  increasingly 
toward  the  middle  or  latter  end  of  the  course.  There  is  almost 
always  very  early  slight  sensitiveness  on  pressure,  but  tenderness 
in  children  is  seldom  extreme,  and  more  apt  to  be  present  along 
with  constipation.  Marked  tympany  is  rare.  Abdominal  pain 
is  absent.  Colic  may  accompany  or  precede  an  action  of  the 
bowels.  The  kidneys  are  seldom  disturbed  seriously.  There 
is  no  constant  relation  between  the  condition  of  the  bowels  and 
the  intestinal  lesions. 

The  heart,  while  enduring  more  readily  the  depressing  effects 
of  the  fever  in  children  than  in  adults,  nevertheless  requires  very 
careful  watching,  as  asthenia  is  by  no  means  rare,  and  collapse 
has  been  known  to  come  without  warning.  Savestre  asserts  that 
syncope  and  death  may  occur  with  the  utmost  suddenness,  and 
that  it  is  more  important  to  watch  the  pulse  than  the  temperature- 
range.  The  disappearance  of  the  first  sound  of  the  heart,  while 
not  a  grave  symptom,  is  an  indication  for  increased  caution  and 
stimulation. 

Relapses,  which  are  as  common  in  children  as  in  adults,  are 
practically  reinfections,  and  are  more  liable  to  occur  after  a  mild 
than  graver  attacks.  One  attack  induces  a  fair,  although  by  no 
means  certain,  immunity  to  subsequent  infection.  Disturbance 
of  the  respiratory  system,  especially  at  the  beginning,  is  so  com- 
mon that  it  may  be  regarded  as  a  phenomenon  of  the  disease. 
Cough  is  common,  without  corresponding  physical  signs.  Bron- 


TYPHOID    FEVER.  625 

chitis,  when  present,  is  usually  of  moderate  intensity.  If  bron- 
chopneumonia  occurs,  the  respiratory  murmur  becomes  much 
weakened,  and  percussion  resonance  is  impaired  on  the  surface 
of  both  lungs.  A  mere  hypostatic  congestion  is  also  not  un- 
common, especially  where  the  circulation  is  enfeebled. 

Complications  and  Sequelae. — In  children  these  are  mild 
and  not  frequent.  Bronchitis  is  a  usual  accompaniment.  Intes- 
tinal hemorrhage,  perforation,  and  peritonitis  are  the  commoner 
and  more  serious  complications.  Nervous  symptoms  are  often 
present,  but  rarely  severe.  Chorea  is  not  uncommon,  and  aphasia 
will  be  found  oftener  than  in  older  patients,  while  posttyphoid 
insanity  is  rare.  Certain  of  the  tissues  are  liable  to  suffer  appar- 
ent parenchymatous  inflammation,  as  the  kidney,  parotid  gland, 
and  muscles.  Otitis  and  parotiditis  are  commoner  than  in  adults. 
Certain  complicating  conditions  involve  the  lungs,  as  thrombosis, 
embolism,  hypostasis,  edema,  and  pneumonia  occasionally.  The 
exanthemata  may  precede,  coexist  with,  or  follow  typhoid  fever. 
So  also  of  diphtheria  and  whooping-cough.  Tuberculosis  does 
occasionally  follow. 

Diagnosis. — In  children,  as  has  been  said,  the  progress  of 
typhoid  fever  is  attended  with  so  much  irregularity  that  the  diag- 
nosis is  oftentimes  exceedingly  difficult,  and  frequently  it  is  not 
recognized  at  all.  Epistaxis  is  rare,  catarrh  of  the  respiratory 
tract  is  common,  and  the  temperature-range  is  more  irregular  than 
in  adults.  Vomiting  is  oftentimes  the  first  symptom.  Neuroses 
are  frequently  prominent,  but  signify  little ;  there  are  often  rest- 
lessness and  delirium,  and  many  times  headache,  but  seldom 
convulsions.  Constipation  rather  than  diarrhea  prevails.  The 
rash,  the  severity  of  which  bears  no  relation  to  the  severity  of 
the  disease,  is  usually  slight ;  fatal  hemorrhage  and  perforation 
are  seldom  seen.  The'characteristic  phenomena  are  the  enlarge- 
ment of  the  spleen,  eruption,  peculiar  temperature-range,  and 
abdominal  distention.  The  method  of  testing  the  blood  after 
the  manner  of  Widal  will  make  the  diagnosis  much  more  exact 
in  future.* 

*  The  Serum  Test  for  Typhoid  Infection. — In  March,  1896,  Pfeiffer  and  Kolle 
published  an  article  in  which  they  claimed  that  the  serum  of  convalescents  from 
typhoid,  when  mixed  with  cultures  of  the  typhoid  bacillus  and  injected  into  the  peri- 
toneal cavity  of  a  guinea-pig,  produced  a  specific  reaction.  The  bacilli  become  agglu- 
tinated and  finally  deformed  and  dissolved,  and  this  change  takes  place  only  with 
typhoid  bacilli  when  typhoid  serum  is  used,  and  is  due  to  the  bactericidal  action  of  the 
typhoid  serum.  This  reaction  was  also  demonstrated  in  a  test-tube,  the  bacilli  falling 
in  fine,  whitish  flakes  and  settling  at  the  bottom  after  a  bouillon  culture  was  mixed 
with  the  serum  from  an  immunized  goat  and  placed  in  the  incubator  for  an  hour. 
The  first  practical  application  of  this  method  of  diagnosis  on  a  large  scale  was  made 
by  Widal,  and  reported  June,  1896,  in  "La  Semaine  Medicale."  He  found  finally 
40 


626  THE    SPECIFIC    INFECTIOUS    DISEASES. 

Apathy,  which  is  occasionally  seen  in  children,  is  rare,  together 
with  subsultus,  coma  vigil,  and  stupor,  so  common  in  adults. 
Gastro-intestinal  disturbance  is  generally  present  from  the  be- 


that  by  drawing  blood  from  the  finger  of  a  typhoid-fever  patient  and  allowing  it  to 
clot  so  that  the  serum  separated,  and  if  such  serum  were  then  added  drop  by  drop  to 
a  broth  culture  in  proportion  of  one  to  ten,  at  the  end  of  twenty-four  hours  the  bacilli 
were  agglutinated  and  immobilized.  Later  he  noted  that  the  dried  serum  and  the 
dried  blood  showed  this  specific  action,  occurring  as  early  as  the  seventh  day  of  the 
fever,  and  remaining  for  a  considerable  period  after  recovery.  Widal  and  Achard 
made  further  tests  to  ascertain  the  properties  of  the  agglutinating  substance.  It  was 
found  in  the  serous  fluid  of  blisters,  serum  from  pus,  tears,  urine,  and  milk  of  persons 
sick  with  typhoid  fever.  This  property  resides  in  the  globulin  and  fibrin,  but  not  in 
the  plasma  of  the  blood.  The  reaction  is  most  pronounced  at  the  height  of  the  infec- 
tion. It  has  disappeared  one  day  and  reappeared  the  next,  but,  as  a  rule,  diminishes 
in  intensity  soon  or  late  after  convalescence — months  or  years.  In  some  cases  it  does 
not  appear  before  the  third  week,  and  rarely  not  at  all.  Wyatt  Johnston,  of  Canada, 
introduced  the  method  into  municipal  laboratories,  and  suggested  that  the  blood  be 
dried  on  a  glass  slide  and  sent  by  the  physician  to  the  laboratory.  The  technic  at 
present  employed  is  to  obtain  a  few  drops  of  blood  from  the  cleansed  finger  or  ear- 
lobe  of  the  patient,  and  allow  it  to  dry  on  a  piece  of  clean  paper  or  a  glass  slide.  This 
specimen  is  then  sent  to  the  laboratory,  where  the  dried  blood  is  mixed  with  five  times 
the  quantity  of  water.  A  drop  of  this  mixture  is  placed  on  a  cover-glass,  and  to  it  is 
added  a  drop  of  a  fifteen-  to  twenty-hour  bouillon  culture  of  the  typhoid  bacillus.  It 
is  then  examined  under  the  microscope  in  a  hanging  drop.  In  a  few  minutes  (five  to 
ten)  the  reaction  occurs,  a  few  bacilli  moving  slowly,  while  the  mass  of  the  bacilli  is 
nearly  motionless  and  clumped  together,  or  all  the  bacilli  may  have  ceased  moving 
and  be  collected  into  clumps.  The  test  is  quantitative,  not  qualitative  ;  agglutinating 
substances  are  present  in  normal  blood,  but  in  far  less  quantity.  In  the  blood  of  a 
sufferer  from  typhoid  fever  the  reaction  takes  place  much  more  quickly  and  effectively 
and  in  greater  dilution ;  the  test,  to  be  proper,  must  occur  in  a  I  :  10  dilution  of 
dried  blood,  and  within  ten  minutes.  In  two-thirds  of  the  cases  of  typhoid  fever  it  is 
possible  to  make  a  positive  diagnosis  by  this  means.  The  absence  of  the  reaction  in 
any  single  examination  does  not  exclude  the  diagnosis  of  typhoid  fever,  but  the  absence 
in  a  series  of  examinations  is  of  value  in  excluding  the  disease.  Opinions  appear  to 
be  divided  as 'to  the  value  of  the  reaction,  some  holding  the  positive  reaction  to  be  of 
decisive  importance,  while  others  assert  that  the  test  is  unreliable  in  a  positive  as  well 
as  a  negative  sense. 

Fischer  ("  Zeits.  f.  Hyg.  u.  Infect,"  1899,  xxxn,  407)  holds,  and  with  reason,  that 
in  all  cases  where  the  reaction  has  been  positive,  it  should"  be  shown  scientifically  that  the 
patient  actually  had  typhoid  fever,  by  the  demonstration  of  the  presence  of  the  bacilli, 
or  that  the  patient  had  not  within  a  reasonable  period  suffered  from  an  attack  of  the 
disease,  and  that  the  proper  dilution  of  the  serum  was  used  in  the  test.  And,  again, 
in  the  event  of  negative  results,  it  should  be  clearly  shown  that  the  patient  was  not 
suffering  from  typhoid.  In  other  words,  it  must  be  shown,  on  unimpeachable  evi- 
dence, that  the  patient  had  or  had  not  the  disease.  Cases  of  positive  results  are 
described  by  Ferraud,  Kasel,  Mann,  and  Fischer,  which  were  evidently  not  typhoid. 
Busch,  Schumacher,  and  Fischer  describe  other  cases  of  unmistakable  typhoid  which 
gave  negative  results. 

It  would  seem,  however,  from  the  cases  at  hand,  that  care  should  be  had  that  the 
serum  should  be  correctly  diluted  ;  also  that  the  observation  be  particularly  made  of 
the  paralysis  rather  than  the  clumping  of  the  bacteria,  and  that,  when  possible,  the 
tests  should  be  controlled  by  bacteriologic  examinations. 

Solutions  of  the  serum  stronger  than  I  :  10  may  give  the  reaction,  even  from 
healthy  blood.  As  a  practical  clinical  point  for  control  examinations  it  might  be 
suggested  that  pure  cultures  of  the  bacteria  can  be  gotten  from  the  urine  of  a  majority 
of  the  patients,  and  this  is  especially  so  when  the  urine  is  found  to  be  cloudy. 

M.  V    BALL. 


TYPHOID    FEVER.  627 

ginning,  but  seldom  in  the  form  of  severe  diarrhea,  and  causes 
this  disease  to  be  readily  confounded  with  pronounced  and  sub- 
acute  disturbances  of  the  digestive  tract.  The  spleen  can  nearly 
always  be  felt,  and  is  increased  in  size.  It  has  been  suggested 
to  puncture  this  in  suspected  cases,  and  to  examine  the  blood 
for  the  bacillus  of  Eberth.  The  rose  spots  will  generally  be 
evident  at  the  end  of  the  second  week,  and  by  this  time  the 
clinical  picture  is  generally  clearly  marked,  the  most  important 
feature  of  which,  as  in  adults,  is  the  temperature-range,  with  its 
morning  remissions  and  evening  exacerbations  in  steady  pro- 
gression to  the  characteristic  gradual  descent.  During  this 
period  the  diseases  with  which  typhoid  fever  may  be  confused 
are  meningitis,  influenza,  tuberculosis,  enterocolitis,  remittent 
fever,  and  even  smallpox  and  trichinosis.  In  meningitis  there 
are  usually  vomiting  at  the  onset,  marked  headache,  and  ten- 
dency to  retraction  of  the  abdominal  walls  ;  in  tuberculosis  the 
temperature-range  is  irregular,  there  is  rarely  tympany,  the  belly 
is  flat,  and  the  delirium,  when  present,  is  apt  to  be  wilder.  In- 
fluenza strongly  resembles  typhoid  fever,  at  least  for  a  short 
time,  but  the  febrile  process  is  more  abrupt,  and  the  organic 
disturbances  are  more  rapid  and  pronounced.  Remittent  fever 
in  malarial  countries  is  a  large  source  of  confusion  with  typhoid, 
and  particularly  so  where,  as  sometimes  happens,  typhoid  fever 
is  modified  by  the  malarial  poison.  The  ready  examination  of 
the  blood  for  the  plasmodium  malariae  will  at  once  make  clear 
that  element.  Simple  continued  fever,  due  to  toxins  produced 
by  disordered  digestion,  should  always  be  borne  in  mind. 
Again,  when  other  cases  are  found  in  the  same  household,  the 
diagnosis  is  rendered  less  difficult. 

Prognosis. — As  has  been  said,  a  statistical  knowledge  of  the 
prevalence  of  typhoid  fever  in  children  is  exceedingly  inexact, 
many  cases  escaping  recognition  altogether.  The  mortality 
among  children  is  certainly  low,  probably  much  less  than  I  per 
cent.  Some  authors  claim  3  to  4  per  cent.  In  those  of  good 
vigor,  not  weakened  by  previous  disease  or  organic  weakness, 
death  is  rare,  and  when  it  does  occur,  is  liable  to  be  due  to  some 
complication  and  not  to  the  disease  itself. 

Treatment. — The  preventive  treatment  of  typhoid  fever  is 
particularly  important,  because  thoroughly  controllable,  but  has 
to  do  rather  with  the  subject  of  hygiene  than  practical  medicine. 
The  water-supply  of  cities  ought  to  be  entirely  free  from  in- 
fection, and  when  this  is  accomplished,  typhoid  fever  will  become 
rare.  Summer  resorts  are  particularly  liable  to  epidemics  of 
typhoid,  where  considerable  crowding  of  an  alien  population 


628  THE    SPECIFIC    INFECTIOUS    DISEASES. 

overtaxes  local  health  precautions  ;  hence  it  is  wiser  to  make 
large  use  of  boiled  water  or  reliable  bottled  waters  when  not 
absolutely  certain  of  the  local  supply.  The  same  may  be  said 
of  milk,  i'n  which  the  typhoid  bacillus  may  readily  appear  and 
grow,  the  source  of  which  may  be  an  infected  cow  or  well. 
The  question  as  to  whether  typhoid  fever  can  be  aborted  or  not 
can  only  be  answered  by  quoting  individual  opinions.  In  a 
suspected  case  the  early  administration  of  calomel  (gr.  j  to  gr. 
iv)  is  a  rational  procedure,  and  is  productive  of  no  harm  and 
possibly  of  much  good  if  resorted  to  in  the  first  three  or  four  days. 
Other  intestinal  antiseptics,  combined  with  laxatives,  may  work 
with  advantage.  In  no  other  disease  is  it  more  important  to 
insist  on  absolute  rest  in  bed  from  the  first  suspicion  to  the  very 
end  of  the  specific  process  and  perhaps  a  little  beyond — at  least 
a  week  or  two.  If  the  child  is  away  from  the  place  where  it 
can  best  be  nursed, — at  its  home  or  a  hospital, — it  is  wise  to  con- 
vey it  there  with  all  due  precautions,  even  at  some  slight  risk. 
A  well-appointed  hospital  is  best  for  rich  or  poor. 

The  diet  must  be  regulated  with  the  utmost  exactitude  as  to 
kind,  quality,  and  hours  of  administration.  Only  fluids  are  safe, 
and  milk  in  some  form  is  the  main  reliance,  and  should  be  con- 
tinued until  apyrexia  has  lasted  about  ten  days.  It  should  be 
sterilized,  Pasteurized,  or  boiled,  and  thus  is  afforded  some  slight 
variety  of  taste  ;  in  other  ways  changes  may  be  wrought  by  dilu- 
tion, as  with  effervescent  waters — Vichy,  Giesshubler,  or  others.  It 
may  be  variously  flavored  or  modified  by  the  addition  of  aromatic 
or  diluent  substances.  Barley-water  and  thin  oatmeal  water  are 
often  excellent  additions.  Milk  is  much  improved  in  its  diges- 
tibility by  being  violently  shaken  in  a  bottle,  where  it  thus 
acquires  a  sparkling  quality  very  grateful  to  a  jaded  stomach. 
Unless  the  digestive  tract  is  in  good  tone,  curds  are  liable  to  form 
in  large  masses  and  fats  to  collect  in  lumps,  and  thus  irritate  the 
intestine  and  work  considerable  mischief.  It  is  sometimes  neces- 
sary to  use  only  skimmed  milk  ;  at  other  times  cream  and  water. 
Where  milk  has  seemed  to  disturb  the  intestines,  it  is  well  to  use 
only  broths  for  a  day  or  two,  or  the  raw  whites  of  eggs  stirred 
up  in  water,  meat-juices,  or  whey.  After  the  stomach  has  thus 
been  rested  milk  may  again  be  used,  preferably  predigested,  alter- 
nating with  some  meat-juice  or  broth,  and  gradually  thus  get 
back  to  a  plain  milk  diet.  Much  ingenuity  should  be  exercised 
with  even  these  fluid  substances,  and  the  urgent  petitions  of  the 
family  to  use  solid  food  be  smilingly  put  aside  by  concessions  of 
this  innocent  sort.  The  addition  of  a  few  drops  of  brandy  or 
whisky  is  sometimes  most  grateful,  and  even  of  Maraschino  or 


TYPHOID  FEVER.  629 

Jamaica  rum.  Indeed,  it  is  well  to  add  a  few  drops  of  some  spirits 
or  of  extract  of  vanilla  to  the  milk  occasionally  by  way  of  a  treat, 
and  especially  to  the  egg-water.  The  fermented  milk  known  as 
koumiss  is  relished  by  some  children,  but  not  by  all.  Well-made 
vanilla  ice-cream,  diluted  with  Vichy, — a  favorite  drink  with  many 
children, — is  also  a  safe  occasional  substitute.  The  amount  of 
milk  necessary  varies  considerably,  a  pint  a  day  being  sufficient 
to  support  life,  especially  if  it  is  well  digested  and  diluted  ;  a  few 
days  later  it  may  be  necessary  to  increase  this,  and  to  decrease 
promptly  if  the  food  distresses.  Three  pints  of  milk  a  day  is 
the  maximum,  beyond  which  it  is  scarcely  safe  to  go.  This  may 
be  supplemented,  however,  by  thin  broths  or  replaced  by  more 
sustaining  meat-extracts.  Many  careful  physicians  allow  for  older 
children  soft-boiled  eggs  occasionally  ;  others  use  thin  gruels  or 
even  milk-toast.  Calf 's-foot  or  wine-jelly  has  a  solid  or  agree- 
able taste,  and  yet  leaves  no  residue  to  irritate  the  intestines. 
Junket  or  coagulated  milk  is  also  of  value.  There  is  a  growing 
confidence  in  the  use  of  a  fuller,  more  varied  dietary  in  uncom- 
plicated cases.  We  enjoy  the  conviction  that  this  is  most  rational, 
and  under  this  system  convalescence  is  earlier  and  much  strength 
conserved.  It  is  often  important  to  use  some  remedies  to  aid 
digestion  ;  the  normal  HC1  is  absent  in  the  height  of  the  fever. 
The  drinking  of  water  should  be  encouraged ;  to  this  may  be 
added  from  five  to  ten  drops  of  hydrochloric  acid  to  a  tumblerful 
of  sweetened  water,  as  a  not  unpleasant  disinfecting  drink  ;  this  re- 
lieves the  condition  shown  by  dry  lips  and  tongue,  which  is  more 
common  among  adults.  Pepsin  with  muriatic  acid  at  times  is 
needed.  If  diarrhea  is  present,  pepsin,  along  with  the  diluted  sul- 
phuric acid,  is  better  ;  brandy  may  be  added  to  this  with  advantage. 
The  physician  must  bear  in  mind  that  relapses  are  due  to  two 
causes  :  one,  not  altogether  under  his  control,  a  reinfection  ;  the 
other,  absolutely  in  his  power,  indiscretions  in  diet  ;  and  from 
this  last  also  frequently  arises  sudden,  unaccountable  death. 
One  week  after  all  fever  has  ceased  we  may  cautiously  begin  the 
use  of  more  solid  foods  ;  here  the  animal  broths  come  in  again, 
in  which  may  be  placed  a  few  stale  bread-crumbs,  bits  of  toast, 
or  Zwieback,  thoroughly  softened  in  milk  or  broths.  A  safe  and 
very  acceptable  dish  is  a  piece  of  not  too  tender  broiled  beef- 
steak, mutton  chop,  or  chicken,  which  is  to  be  masticated  and 
only  the  juice  swallowed  ;  but  the  mere  act  of  chewing  is  a  great 
joy  to  a  hungry  child.  This  may  be  usually  allowed  from  the 
beginning  or  middle  of  the  second  week.  Then  come  scrambled 
eggs  and  scraped  meat,  rice-  and  milk-pudding,  and  finally  the 
various  bread  preparations,  carefully  selected. 


630  THE    SPECIFIC    INFECTIOUS    DISEASES. 

Baths. — For  the  treatment  of  the  fever  antipyretic  drugs  are 
to  be  avoided  or  most  cautiously  administered,  the  main  reliance 
for  lowering  the  temperature  being  upon  cool  or  cold  baths. 
There  is  no  danger  of  the  child  taking  cold  when  the  tempera- 
ture exceeds  102°  F.  (38.8°  C).  Cloths  wrung  out  of  cool  water 
(80°  to  60°  F.),  laid  upon  the  body  and  head,  will  also  be  found 
grateful.  A  more  effectual  method  is  for  the  child  to  be  entirely 
swathed  in  these,  beginning  with  warm  water  at  95°  F.  (35°  C.), 
and  replacing  by  cooler  and  cooler  water,  80°  to  60°  F. ;  or  a  piece 
of  rubber  cloth  may  be  slipped  under  the  child,  the  four  sides 
propped  up,  and  tepid  (85°  F.)  or  cool  water  (75°  to  70°  F.) 
poured  in,  forming  a  superficial  bath.  This  is  known  as  the 
wet-pack  and  should  be  continued  for  at  least  ten  to  thirty 
minutes.  In  hyperpyrexia  with  delirium  the  patient  may  be 
placed  in  a  full  bath  with  great  advantage,  or  use  the  cold  pack 
with  iced  water.  Full  directions  for  bathing  are  given  in  another 
place.  At  all  times  the  temperature  should  be  carefully  watched 
to  see  that  we  are  not  producing  a  condition  of  collapse ;  if  so, 
or  if  the  extremities  grow  cold,  dry  heat  must  be  promptly 
applied,  with  stimulants  by  the  mouth  or  rectum  or  hypodermi- 
cally.  The  inhalation  of  oxygen  is  often  used.  ,Cold  baths  or 
applications  are  rarely  contraindicated,  except  when  there  is  a 
marked  depression  of  the  circulation  or  when  a  hemorrhage  from 
the  bowels  is  threatened,  and  then  only  on  account  of  the  dis- 
turbance caused  to  the  abdomen  and  intestines  in  the  handling 
of  the  patient. 

A  valuable  adjuvant  to  the  cold  bath  in  hyperpyrexias  is  the 
maintenance  of  a  cool  temperature  in  the  room,  by  the  free 
opening  of  the  windows,  even  if  the  temperature  of  the  room 
remains  stationary  at  60°  F.,  and  it  is  equally  important  that  the 
patient  should  only  be  covered  by  a  sheet  or  very  thin  blanket. 
In  this  there  is  no  danger  and  practically  no  discomfort,  so  long 
as  the  temperature  remains  at  or  near  102°  F.  (38.8°  C.).  For 
older  children  the  full  directions  for  bathing  as  outlined  by 
Brand  are  to  be  followed. 

Drugs. — Of  the  coal-tar  antipyretics,  antipyrin  and  phenacetin 
are  preferred  by  some  and  acetanilid  by  others  ;  guaiacol, 
locally,  has  many  adherents,  but  its  effect  is  transitory  and 
should  be  carefully  watched  when  applied.  Quinin,  if  there  is 
malarial  complication,  acts  happily,  but  is  capable  of  doing 
harm.  It  is  best  given  by  the  rectum.  If  antipyretics  are  used, 
it  is  well  to  combine  with  them  some  stimulant  or  cardiac  tonic, 
as  strychnin.  The  use  of  the  occasional  antipyretics,  acetanilid 
or  phenazone,  along  with  the  tepid  bath  or  sponging  and  a  little 


TYPHOID    FEVER.  63  I 

brandy  or  wine  whey,  gives  most  gratifying  results.  For  tym- 
pany,  enemata  of  iced  water,  alone  or  in  combination  with  some 
carminative,  as  fennel,  catnip,  or  camomile  water,  or  with  one 
or  two  teaspoonfuls  of  turpentine  (emulsified  by  white  of  egg), 
relieves  admirably.  Turpentine  by  the  mouth  is  perhaps  the 
most  satisfactory  of  all  remedies  to  relieve  abdominal  distention 
or  intestinal  distress,  which  so  frequently  arises  during  the 
second  week,  and  is  especially  indicated  when  the  dry,  dark-brown 
tongue  appears.  Where  there  is  diarrhea  also,  the  turpentine 
may  be  administered  with  aromatic  sulphuric  acid  ;  to  this  may 
be  added  bismuth,  naphthalin,  salol,  or  a  minim  or  two- of  tinc- 
ture of  opium.  It  is  sufficient  to  give  turpentine  (gtt.  iij  to  gtt. 
vj  in  emulsion  or  in  the  white  of  egg)  every  four  hours  for 
meteorism,  but  to  check  diarrhea  these  and  the  other  substances 
just  mentioned  should  be  given  every  hour  or  two  while  de- 
manded, and  the  interval  lengthened  when  this  ceases.  Tincture 
of  asafetida  is  useful  here.  One  of  the  most  powerful  astrin- 
gents, and  yet  a  safe  one,  is  acetate  of  lead.  Collapse  calls  for 
powerful  stimulants  by  the  mouth,  rectum,  and  subcutaneously — 
dilute  alcohol,  caffein,  musk,  camphor  in  sweet  almond  oil,  I  :  4, 
and  benzoate  of  sodium  are  the  best  to  employ. 

Chloral  is  of  value  when  insomnia  or  great  excitement  pre- 
vails, but  should  the  heart  be  enfeebled,  croton  chloral  is  prefer- 
able. Should  heat  in  the  head  accompany  these  symptoms, 
cold  applications  of  iced  water  or  an  ice-cap  is  very  soothing, 
and  the  head  should  be  kept  as  high  as  comfort  will  allow. 

For  constipation,  which  is  as  common  as  diarrhea  is  children,  it 
is  perhaps  best  to  wash  out  the  lower  bowel  every  other  day  with 
warm  water.  To  the  rectal  injections  may  be  added  turpentine 
or  castor  oil,  or  both.  A  valuable  internal  remedy  is  olive  oil  in 
good-sized  doses  :  entirely  harmless,  laxative,  nutritive,  and  pro- 
tective to  inflamed  surfaces.  When  diarrhea  is  present,  frequent 
irrigation  with  water  at  about  100°  F.  (37.7°  C.)  is  useful. 
Should  the  discharges  be  offensive,  the  addition  of  thymol  or 
permanganate  of  potassium  is  advised ;  here  the  internal  use 
of  bismuth,  salol,  or  naphthalin  is  recommended  by  some. 
Tympanites  is  to  be  combated  with  turpentine  stupes,  a  flannel 
cloth  wet  with  and  wrung  out  of  a  mixture  of  one  tablespoonful 
to  a  pint  of  hot  water ;  by  the  internal  use  of  thymol  or  tur- 
pentine ;  and  when  a  grave  complication,  by  hot  enemata.  If 
hemorrhage  occurs,  food  must  be  withheld  altogether  for  a 
time ;  when  given,  it  should  be  in  small  amounts  and  cold,  and 
an  ice-bag  applied  to  the  right  iliac  region.  As  hemostatics 
turpentine  and  ergotin  hypodermically  or  gallic  acid  act  hap- 


632  THE    SPECIFIC    INFECTIOUS    DISEASES. 

pily.  Hemorrhage  in  the  typhoid  fever  of  children  is  liable  to 
cease  soon,  and  too  much  interference  should  be  avided.  If 
symptoms  of  perforation  become  evident,  a  surgeon  skilled  in 
abdominal  section  should  be  called  in  consultation,  who,  by 
prompt  operation,  may  sometimes  save  life.  Hypostatic  conges- 
tion should  be  prevented  as  much  as  possible  by  shifting  the 
position  slightly,  which  is  easily  done  by  wedging  up  the  mat- 
tress or  the  sheet  an  inch  or  two  under  the  side  of  the  child, 
leaving  it  so  for  an  hour  or  more,  withdrawing  this  and  shifting 
the  wedge,  which  may  be  a  folded  towel  or  a  roll  of  cloth,  to 
the  other  side,  and  raising  it  an  inch  or  more  ;  thus  the  attitude 
of  the  child  is  changed  a  little  and  the  blood  encouraged  to 
gravitate  obliquely  in  these  successive  directions  rather  than 
vertically.  Pain  in  the  legs  frequently  results  from  their  long- 
continued  extension,  and  is  relieved  by  supporting  the  knees  on 
a  folded  Turkish  towel  or  small  pillow. 

DIPHTHERIA. 

Diphtheria  is  an  acute,  infectious,  and  inoculable  disease,  of 
bacterial  origin,  occurring  sporadically  and  epidemically.  It  is 
characterized  clinically  by  a  specific  inflammation  of  the  mucous 
membrane  of  the  throat,  followed  by  the  formation  of  a  mem- 
branous exudate  upon,  and  resulting  in  a  local  necrosis  of,  the 
parts  affected,  and  by  the  development  of  a  peculiar  toxemia. 

This  disease  usually  selects  for  its  site  the  pharynx  and 
upper  air-passages  ;  it  also  appears  in  the  nose,  and  exhibits  a 
marked  tendency  to  spread  to  other  mucous  surfaces,  even  to 
the  utmost  ramifications  of  the  bronchi,  and  is  attended  with  en- 
gorgement of  the  associated  lymphatic  glands.  Occasionally  it 
attacks  the  abraded  surfaces  of  the  skin  and  the  freshly  cut  sur- 
faces of  recent  operations. 

Constitutionally,  diphtheria  is  marked  by  irregular  fever  and 
pronounced  debility,  and  it  is  frequently  accompanied  by  albu- 
min uria.  Death  is  brought  about  usually  by  toxemia,  heart 
failure,  or  mechanical  obstruction  of  the  air-passages  by  exten- 
sion of  the  fibrinous  exudate.  It  is  followed  by  a  slow,  irregular 
convalescence,  sometimes  by  lymphatism,  and  in  severe  cases  by 
a  peculiar  blood  cachexia  resulting  in  marasmus,  and  frequently 
by  peculiar  forms  of  paralysis. 

Causes. — Diphtheria  is  a  disease  caused  by  the  activity  of  the 
bacillus  diphtheriae  (Klebs-Loeffler).  Several  microbes  are  found 
associated  with  this  in  the  mouth  and  throat,  among  others  the 
staphylococcus  albus  and  aureus  and  the  streptococcus  pyogenes, 


DIPHTHERIA. 


633 


which  may  themselves  become  active  and  alter  the  course  of  the 
disease.      (See  Septicemia.)     Certain  harmless  microbes  may  also 


FIG.  40.— SKIAGRAM  OF  A  WELL-DEVELOPED   MALE  INFANT  A  FEW  HOURS  AFTER   BIRTH 
(O'Dwyer's  intubation  tube  still  in  the  throat). 

be  present,  and  even  accumulate  in  the  lymph-vessels  leading 
from  the  inflamed  surface. 

By  some  diphtheria  is  still  regarded  as  a  constitutional  disease, 
with  a  local  manifestation,  developed  during  its  course.     The 


634  THE    SPECIFIC    INFECTIOUS    DISEASES. 

preponderance  of  the  clinical  and  bacteriologic  proof  is  in  favor 
of  the  view  that  it  begins  as  a  local  malady.  The  bacillus  diph- 
theriae  was  discovered  by  Klebs  in  1883,  and  Loeffler  in  1884, 
who  was  the  first  to  isolate  and  cultivate  the  micro-organism, 
which  bears  the  joint  name,  Klebs-Loeffler.  Inoculation  into  the 
lower  animals  produces  the  characteristic  syndrome  of  diphtheria, 
which  is  the  formation  of  false  membranes  with  an  underlying 
necrosis,  along  with  paralysis  and  albuminuria.  The  bacillus 
produces  certain  ptomains  or  toxins,  which  are  absorbed  by  the 
lymphatics  and  blood-vessels  and  give  rise  to  serious  constitu- 
tional symptoms.  The  bacilli  themselves  are  regarded  as  harm- 
less, except  for  the  power  to  produce  specific  ptomains.  The 
isolated  toxin,  if  introduced  in  small  increasing  amounts  into  the 
circulation  of  animals,  produces  an  increasing  degree  of  immun- 
ity. The  serum  of  such  immunized  animals  produces  immunity 
in  man.  The  action  of  the  attenuated  diphtheric  virus  when  in- 
jected into  man  or  animals  destroys  the  toxins  formed  by  the 
bacilli,  but  not  the  bacilli  themselves.  This  constitutes  a  biologic 
antidote. 

Diphtheria  is  common  among  certain  of  the  domestic  animals, 
particularly  cats.  It  is  easily  transmitted  from  animals  to  man, 
and  conversely.  Cows  which  have  recently  calved  frequently 
suffer  from  an  affection  which  dairymen  call  "chapped  teats." 
This  has  been  found  to  be  identical  with  the  condition  produced 
by  inoculating  the  teats  with  Klebs-Loeffler  bacilli.  When  it  is 
taken  into  consideration  how  favorable  a  medium  for  the  cultiva- 
tion of  the  diphtheria  bacillus  cow's  milk  is,  and  how  rapidly 
these  germs  multiply,  an  epidemic  of  diphtheria  may  thus  be 
easily  started. 

There  is  ground  for  belief  that  there  are  two  varieties  of  diph- 
theria bacilli — the  one  virulent  (pathogenic)  and  the  other  harm- 
less (nonpathogenic).  An  innocent  variety  of  diphtheria  germ  is 
often  to  be  found  in  the  pharynx  of  healthy  children  and  others. 
False  membrane  appears  upon  the  mucous  surfaces  from  various 
causes,  chiefly  from  irritation  other  than  that  of  diphtheria.  The 
habitat  of  the  microbe  when  outside  of  the  body  is  not  yet  clearly 
understood,  but  it  is  found  in  filthy  accumulations,  especially  of 
human  and  animal  refuse,  and  has  a  marked  causal  relationship 
to  damp  localities.  It  has  been  noted  that  diphtheria  began 
after  the  use  of  horse  manure  on  a  field  or  garden  spot  in  a 
locality  hitherto  free. 

Diphtheria  is  transmitted  usually  by  direct  contagion,  although 
it  is  capable  of  transference  by  various  means  and  is  inocul- 
able.  Diseased  or  abraded  surfaces  are  far  more  susceptible 


DIPHTHERIA.  635 

than  healthy  ones,  and  mucous  surfaces  are  the  usual  site.  The 
radius  of  contagion  is  limited  to  a  few  feet,  and  with  reason- 
able precaution  it  is  not  dangerous  to  approach  one  so  affected. 
Unhygienic  conditions,  such  as  dampness,  darkness,  and  the  like, 
not  only  favor  the  spread  of  diphtheria,  but  lower  the  resistance 
of  those  who  live  under  such  devitalizing  conditions.  Direct 
contagion  is  not  nearly  so  large  a  factor  in  the  propagation 
of  diphtheria  as  foul  drains  and  filthy  collections  of  animal 
refuse.  Children  are  much  more  susceptible  to  diphtheria  than 
older  persons,  but  the  disease  may  occur  at  any  period ;  white 
children  under  five  are  most  susceptible  (Billings).  The  propa- 
gation is  favored  by  cold  and  damp  weather,  unhygienic  sur- 
roundings, excessive  exposures,  and  overcrowding.  One  attack 
does  not  confer  immunity,  but,  on  the  contrary,  seems  to  render 
one  more  susceptible  to  the  disease.  Diphtheria  may  accom- 
pany other  diseases,  especially  acute  disorders  of  the  throat.  Epi- 
demics of  diphtheria  are  apt  to  follow  the  prevalence  of  other 
contagious  diseases.  Diphtheria  and  typhoid  fever  frequently 
prevail  at  the  same  time  and  in  the  same  locality.  Laryngeal 
diphtheria  frequently  complicates  measles,  and  is  a  most  fatal 
sequel  thereto. 

Pathology. — In  diphtheria  the  inflammatory  processes  are 
more  commonly  confined  to  the  fauces,  tonsils,  and  pharynx, 
although  they  frequently  extend  to  the  nose,  trachea,  and  bronchi, 
and  occasionally  to  the  mouth,  lips,  esophagus,  conjunctiva, 
middle  ear,  stomach,  and  genitalia.  It  may  also  affect  freshly  cut 
surfaces,  notably  tracheotomy  wounds,  the  prepuce  in  circum- 
cision, and  the  umbilicus  in  the  new-born. 

The  membrane  presents  at  first  a  whitish,  then  an  opalescent, 
and  finally  a  muddy  gray,  appearance ;  in  the  last  stage  it  re- 
sembles a  necrotic  portion  of  mucous  membrane.  This  false 
membrane  is  very  adherent,  but  when  forcibly  removed,  displays 
a  hyperemic  mucous  membrane  beneath,  usually  intact,  and  only 
rarely,  except  on  the  tonsils,  is  there  a  tendency  to  ulceration. 
During  the  progress  of  the  disease  the  exudate  becomes  quite 
thick,  and  is  composed  of  several  layers  of  fibrin,  the  lower  ones 
being  the  most  recent  in  formation.  In  the  tonsillar  variety  it 
may  be  in  such  mass  as  to  block  the  passages  between  them  com- 
pletely. If  the  membrane  covers  the  pharynx  and  uvula,  it  may 
appear  as  one  sheet,  and  when  separating,  may  do  so  in  a  mass, 
leaving  a  healthy  mucous  membrane  beneath. 

In  the  nasal  variety  the  membranes  are  thickened,  of  pinkish 
color,  and  separate  in  mass.  In  the  laryngeal  variety  the  mem- 
brane is  white,  sometimes  pinkish,  and  may  extend  to  the  trachea 


636  THE    SPECIFIC    INFECTIOUS    DISEASES. 

or  even  to  the  bronchi,  and  may  also  be  rejected  in  mass,  exhibit- 
ing a  cast  of  the  parts  obstructed.  The  lymph-nodes  of  the  cer- 
vical region  are  veiy  frequently  affected.  The  spleen  is  enlarged 
and  congested,  and  the  pulp  is  softened.  The  liver,  also,  is  con- 
gested, with  areas  of  necrotic  cells  peculiar  to  this  disease.  In 
the  kidneys  hyaline  changes  in  the  glomerular  capillaries  and 
small  arteries  are  characteristic  features  of  the  nephritis  of  diph- 
theria, according  to  Welsh. 

In  malignant  cases  dying  early  cardiac  thrombi  are  found,  and 
the  heart  muscles  are  invariably  affected.  Degenerative  changes 
have  been  demonstrated  in  the  cord  and  spinal  nerves,  as  well  as 
in  the  pneumogastric  and  accessory  nerves. 

Bauer  and  Deutsch,  who  examined  the  stomach-contents  of  a 
large  number  of  children  suffering  from  diphtheria,  found  that  in 
no  case  was  there  free  hydrochloric  acid  present,  and  the  amount 
of  the  combined  acids  was  lessened.  After  the  injection  of  anti- 
toxin the  free  hydrochloric  acid  reappeared  in  the  majority  of 
instances  in  from  twenty-four  to  forty-eight  hours.  When  it  did 
not,  the  amount  of  the  combined  acids  was  greatly  increased.  In 
fatal  cases  which  had  been  injected  the  free  hydrochloric  acid  did 
not  reappear  at  all,  and  this  may  be  of  value  in  prognosis.  In 
cases  treated  without  antitoxin  free  hydrochloric  acid  did  not 
come  back  until  full  convalescence.  The  motility  of  the  stomach 
was  in  proportion  to  the  amount  of  acid.  The  absorption  re- 
mained normal. 

Bronchopneumonia,  edema  of  the  lungs,  and  emphysema  are 
also  frequent  sequences,  and  by  reason  of  the  various  pathologic 
changes  the  blood  itself  is  altered,  a  reduction  being  found  in  the 
number  of  the  red  corpuscles  as  well  as  of  the  hemoglobin. 

The  Membrane. — The  fibrinous  network  contains  within  its 
meshes  numerous  epithelial  cells,  leukocytes,  serous  exudate,  and 
diphtheria  bacilli.  The  upper  layers  of  the  membrane  also  con- 
tain great  quantities  of  cocci,  which,  however,  bear  no  known  rela- 
tion to  the  etiology  of  the  disease.  The  mucous  membrane  itself 
shows  inflammatory  infiltration. 

Symptoms. — The  incubation  period  of  diphtheria  varies  from 
two  to  ten  days,  according  to  the  severity  of  the  epidemic  and 
the  physiologic  resistance  of  the  patient.  The  symptoms  are 
both  local  and  constitutional.  Mild  and  malignant  cases  de- 
velop near  and  from  each  other. 

The  prodromes  of  diphtheria  resemble  those  of  other  infec- 
tious diseases,  exhibiting  slight  chills,  moderate  fever,  malaise, 
and  some  degree  of  pain  in  the  back  and  limbs.  In  the  onset 
of  very  mild  cases  the  symptoms  may  be  trifling,  so  that  the 


DIPHTHERIA.  637 

patient  is  soon  up  and  around.  As  a  rule,  fever  in  the  first 
twenty-four  hours  of  the  attack  may  reach  102°  or  103°  F.  (38.8° 
to  39.4°  C.)  ;  in  severe  cases  the  temperature  may  be  subnormal. 
The  course  is  quite  irregular.  The  pulse  is  rapid  and  feeble, — 
from  100  to  120  beats  a  minute  ;  sometimes  a  drop  of  one  in 
twenty  beats  occurs, — and  very  frequently  it  is  dicrotic.  The  first 
well-marked  symptoms  in  a  typical  case  are  usually  those  of 
throat  inflammation  :  the  little  patient  complains  of  difficulty  in 
swallowing,  feels  tender  under  the  jaw,  and  somewhat  stiff  in  the 
muscles  of  the  neck.  In  twelve  or  twenty -four  hours  from  the 
onset  a  grayish  pellicle  often  forms  upon  the  tonsils,  and  the 
cervical  glands  will  be  found  swollen. 

The  most  characteristic  feature  is  the  constitutional  distur- 
bance with  marked  debility,  which  is  out  of  proportion  to  the 
severity  of  the  fever.  At  first  the  throat  may  show  nothing,  or 
be  only  hyperemic  and  swollen.  Spots  may  not  be  seen  at  first, 
or  begin  as  small,  adherent  patches,  grayish  or  yellowish  white, 
usually  upon  the  inner  surface  of  one  or  both  tonsils.  These 
may  at  first  be  scarcely  perceptible,  except  as  slight  opacities, 
but  the  tendency  is  to  spread,  covering  the  tonsils  and  meeting 
in  the  center.  There  is  little  or  no  pain,  or  it  may  become 
severe.  Weakness  and  pallor  increase.  The  course  of  the 
fever  is  irregular.  The  heart  early  shows  special  enfeeblement, 
the  breath  becomes  fetid,  and  the  tongue  is  usually  coated  and 
swollen.  The  appetite  disappears,  nausea  may  appear,  and  the 
bowels  become  costive.  The  glands  of  the  neck  are  usually 
swollen,  sometimes  symmetrically.  The  urine  may  grow  scanty 
and  highly  colored,  or  maintain  a  natural  appearance,  with 
albumin  showing  in  two  or  three  days.  In  mild  cases  the 
symptoms  subside  in  a  week  or  ten  days,  the  patient  becoming 
much  enfeebled  and  convalescing  slowly ;  in  severe  cases  the 
weakness  grows  extreme,  and  the  obstructive  symptoms  pro- 
gress. If  the  nose  is  involved,  there  are  the  usual  symptoms  of 
obstruction,  and  the  secretions  excoriate  the  upper  lip  and  emit 
an  extremely  offensive  odor.  The  glands  about  the  jaws  and 
neck  become  enlarged  and  tender,  especially  when  the  nose  is 
affected,  sometimes  involving  the  connective  tissue,  stiffening  the 
whole  neck.  When  the  larynx  is  first  attacked,  it  usually 
begins  on  the  third  or  fourth  day,  and  is  shown  by  hoarseness 
and  obstructed  breathing,  with  a  peculiar  croupy  cough  and 
symptoms  of  cyanosis,  with  increasing  dyspnea.  (See  Membran- 
ous Croup.)  The  coughing-up  of  bits  of  membrane  may  relieve 
this  for  a  time,  but  the  membranes  soon  form  again  and  the 
trouble  may  return  and  become  urgent  for  relief.  During  the 


638  THE    SPECIFIC    INFECTIOUS    DISEASES. 

progress  of  this  local  disturbance  the  constitutional  symptoms 
are  liable  to  grow  worse,  with  depression  of  pulse  and  circulation 
and  increase  in  the  kidney  complications,  casts  and  blood-cells 
showing  in  the  urine  ;  along  with  this  is  an  extreme  prostration. 
Death  may  result  from  suffocation  unless  the  symptoms  are  re- 
lieved by  intubation  or  tracheotomy. 

The  difficulty  of  breathing  may  be  due  to  increase  in  the 
amount  of  membrane,  from  swelling  of  the  false  membrane,  the 
detachment  of  a  portion  stopping  up  the  glottis,  or  acute  en- 
gorgement of  hypertrophied  tonsils  already  existing  ;  or  else,  on 
the  one  hand,  the  difficult  breathing  may  be  due  to  altered  blood 
states,  by  reason  of  accumulation  of  waste  matter  in  the  blood, 
causing  systemic  depression  by  autointoxication,  with  subsequent 
heart  failure.  On  the  other  hand,  the  altered  blood  disturbs  the 
respiratory  center  and  thus  causes  dyspnea,  or,  finally,  by  accu- 
mulations of  poisonous  waste  matter  and  consequent  systemic 
depression,  heart  failure  is  induced. 

Albuminuria  is  present  in  nearly  all  well-marked  cases,  usually 
appearing  between  the  third  and  the  tenth  day ;  this  may  be  due 
to  acute  nephritis  or  to  the  effect  of  the  toxins  on  the  glomerular 
epithelium  of  the  kidneys,  or  from  imperfect  aeration  of  the  blood 
in  the  late  stages  of  the  disease. 

Albuminuria  is  attributable  to  changes  in  the  epithelium,  the 
"acute  degeneration"  of  Delafield.  This  change  is  brought  on 
by  the  febrile  state,  causing  cloudy  swelling  of  the  epithelium  of 
the  tubules.  The  amount  of  albumin  is  slight  and  usually  dis- 
appears with  the  subsidence  of  fever,  or  albuminuria  may  result 
from  the  circulation  in  the  blood  of  abnormal  and  irritating 
ingredients.  This  malady  rarely  leaves  serious  kidney  trouble 
behind  it. 

The  pulse  is  nearly  always  rapid,  and  if  it  falls  below  the  nor- 
mal, is  a  sign  of  serious  cardiac  weakness.  Tirard  says  the  chief 
characteristic  of  the  pulse  of  diphtheria  is  its  disproportionate 
rapidity  as  compared  with  the  temperature.  He  also  calls  atten- 
tion to  the  early  loss  of  the  knee-jerk  in  the  first,  second,  or 
third  day,  and  this,  he  claims,  is  a  valuable  aid  in  diagnosis. 

A  certain  number  of  cases  assume  a  malignant  type  even  from 
the  very  beginning,  and  the  system  becomes  overwhelmed  with 
the  intensity  of  the  poison  ;  or  the  severity  of  the  disease  may 
show  itself  in  excessive  membrane  formation.  The  average  dura- 
tion is  about  ten  days  or  two  weeks,  but  mild  cases  recover  in  a 
few  days.  Severe  and  protracted  attacks  of  the  disease  may  last 
for  weeks. 

The   paralyses  which  follow   diphtheria  are  due    to    trophic 


DIPHTHERIA.  639 

changes,  and  may  be  sensory,  but  are  usually  only  motor.  They 
are  peculiar  in  many  ways  :  One  set  of  muscles  may  be  losing  its 
force  while  another  is  regaining,  but  all  are  likely  to  get  well  in 
the  long  run.  The  knee-jerks  are  usually  absent,  and  there  is 
little  or  no  pain  or  tenderness.  The  part  usually  affected  is  the 
soft  palate,  which  loses  both  power  and  sensibility  and  also  con- 
trol over  the  acts  of  swallowing  and  speaking.  The  muscles  of 
the  eye  are  sometimes  paralyzed  ;  also  one  or  both  vocal  cords  ; 
or,  again,  the  diaphragm  of  cervical  muscles,  sometimes  the 
sphincters  of  the  bladder  and  rectum,  and  frequently  the  whole 
lower  extremities.  (See  Neuritis.) 

Diagnosis. — Since  the  discovery  of  antitoxin  and  the  specific 
results  of  its  early  use,  greater  efforts  have  been  made  for  an 
early  diagnosis.  Certain  specialists  in  diseases  of  the  throat,  and 
some  who  regard  themselves  as  such,  claim  that  they  can  differ- 
entiate between  the  simpler  inflammations  of  the  throat  and  the 
milder  forms  of  diphtheria.  To  a  limited  extent  this  is  true,  but 
such  diagnosis  is  not  to  be  relied  upon.  The  bacteriologic  dem- 
onstration of  the  Klebs-Loeffler  bacillus,  which  can  now  be 
secured  with  great  promptitude  and  more  or  less  thoroughness 
in  all  our  larger  and  in  many  of  our  smaller  cities,  is  the  most 
reliable  guide.  But  this  also  has  its  limitations,  as  has  been  well 
said  by  Welch  :  The  mere  presence  of  the  diphtheria  bacilli  in 
the  throat  of  a  patient  no  more  proves  that  he  has  diphtheria 
than  the  presence  of  the  pneumococcus  in  his  saliva  establishes 
the  fact  that  he  has  pneumonia.  The  only  decisive  method,  as 
claimed  with  much  justice  by  Runge,  is  control  experiments  in 
the  way  of  animal  inoculations.  In  the  concealed  forms  of 
diphtheria,  as  in  the  trachea  or  the  nares,  the  difficulties  of  diag- 
nosis are  large.  But  it  is  always  safe  to  assume  that  a  case  is 
diphtheria  when  the  very  slightest  patch  appears  before  or  after 
or  during  a  croupy  paroxysm,  even  should  such  a  patch  appear 
upon  the  tonsil,  uvula,  pharynx,  or  palate.  The  differentiation 
between  croup  and  diphtheria  is  clinically  separated,  although  in 
certain  instances  the  diphtheria  bacilli  are  demonstrated  in  the 
membranes  of  croup,  and  often  absent  in  cases  of  croup  resem- 
bling diphtheria.  It  is  safe  practice  always  to  treat  as  diphtheria 
those  cases  of  croup  which  become  progressively  worse,  or  which 
fail  to  respond  to  judicious  medical  treatment  after  the  first 
twenty-four  hours.  Croup  is  a  local  disease,  albuminuria  is 
absent,  the  lymphatic  glands  are  rarely  enlarged,  and  no  paralyses 
follow.  The  necrotic  change  is  more  superficial  than  in  diph- 
theria. Where  croup  appears  secondary  to  other  diseases,  such 
as  measles,  scarlet  fever,  or  the  like,  it  is  -always  safe  to  look 


640  THE    SPECIFIC    INFECTIOUS    DISEASES. 

upon  this  complication  clinically  as  diphtheria,  and  treat  it  at 
once  as  such.  (See  Membranous  Croup.) 

Scarlatina  exhibits  a  sore  throat  closely  resembling  diphtheria, 
although  the  two  diseases  may  coexist.  The  scarlatinous  throat 
is  much  more  diffusely  red  than  in  diphtheria.  There  is  also  the 
characteristic  tongue,  but  in  the  membranous  anginas  of  scarlet 
fever,  if  the  complication  is  not  diphtheria,  the  patches  will  be 
found  on  both  tonsils,  and  the  tonsils,  as  well  as  the  lymphatic 
glands,  will  invariably  be  found  enlarged  and  swollen.  The 
membranes  in  scarlet  fever  are  found  soft  and  spongy,  and  appear 
to  be  embedded  in,  and  not  upon,  the  tonsil,  as  is  always  seen  in 
diphtheria.  Bacteriologic  examination  shows  the  streptococci  in 
scarlet  fever,  and  not  the  diphtheria  bacilli,*  unless  this  last  is  a 
complication.  In  case  of  doubt  it  is  a  safe  practice  to  administer 
the  antitoxin,  and  where  there  is  mixed  infection,  the  additional 
use  of  the  antistreptococcic  serum  is  indicated. 

Certain  patients  are  met  with  who  exhibit  pseudomembranes, 
and  cases  of  follicular  tonsillitis  with  large  exudation  give  much 
concern.  (See  Tonsillitis.)  Where  the  history  points  to  exposure, 
it  is  always  a  safe  practice  to  give  a  curative  dose  of  the  antitoxin, 
even  though  the  question  of  diagnosis  be  a  debatable  one.  Every 
condition  of  acute  sore  throat  in  a  child  should  be  viewed  with 
suspicion,  and  none  is  too  trifling  to  warrant  the  omission  of  a 
bacteriologic  test.  When  a  test  is  impracticable,  certain  clinical 
manifestations  enable  us  to  decide  with  some  certainty. 

The  question  of  infection  always  enters  into  the  discussion  of 
diagnosis,  and  while  the  infectiousness  of  diphtheria  can  not  be 
questioned,  that  of  allied  diseases  might.  It  is,  therefore,  sound 
practice  always  to  isolate  a  case  of  throat  disease  which  presents 
an  exudate,  for  clinical  as  well  as  bacteriologic  tests  have  proved 
that  they  are  most  always  contagious  diseases. 

Prognosis. — The  vigor  of  the  individual  is  little  or  no  guide 
as  to  the  likelihood  of  recovery.  When  important  organs  are 
seriously  damaged,  the  case  is  more  desperate.  Paralyses  may 
arise  as  readily  in  originally  strong  as  in  weaker  children.  The 
severity  of  diphtheria  varies  considerably  in  different  epidemics, 
but  at  any  moment  septic  conditions  may  arise  in  even  the 
mildest  cases,  ending  fatally.  The  earlier  the  treatment, — it 
matters  little  what  plan  is  used, — the  better  the  prognosis.  The 
quantity  of  membrane  is  usually,  but  not  always,  an  index  of  the 
severity  of  the  disease.  The  laryngeal  form  is  liable  to  be  fatal 


*  Dr.  Wm.  M.  Welch,  at  the  Municipal  Hospital  of  Philadelphia,  finds  the  Klebs- 
Loeffler  bacillus  in  one-third  of  all  cases  of  scarlatina. 


DIPHTHERIA.  64! 

from  mechanical  interference  with  breathing.  When  diphtheria 
involves  the  nose,  danger  is  great,  because  of  the  greater  vascu- 
larity  and  abundant  lymphatic  vessels  there  which  readily  absorb 
septic  material.  Scrofulous  children  succumb  readily  to  diph- 
theria, and  so  do  those  convalescing  from  measles.  The  death- 
rate  of  diphtheria  was  from  40  to  75  per  cent.,  and  until  recently, 
despite  all  efforts  to  the  contrary,  this  has  remained  about  the 
same.  Half  the  fatal  cases  are  under  five  years  of  age.  Since 
the  advent  of  antitoxin,  the  mortality  records  have  been  reduced 
materially. 

Treatment. — Prophylaxis.-— The  most  important  point  in  the 
treatment  of  diphtheria  is,  without  doubt,  a  thorough  and  wide- 
spread popular  knowledge  of  the  subject  and  the  possible  means 
of  its  prevention.  This  will  enable  not  only  the  medical  adviser 
to  limit  the  spread  of  the  disease  on  making  its  appearance,  but 
elicits  the  assistance  and  cooperation  of  the  family  and  the  com- 
munity. Isolation  of  the  patient  should  be  prompt  and  com- 
plete, and  maintained  so  long  as  the  germs  exist  in  the  throat. 
The  time  of  its  disappearance  may  vary  from  a  few  days  to,  in 
one  reported  instance,  seven  months.  One  observer  has  re- 
ported several  cases  in  whom  the  germ  persisted  for  forty  days  ; 
the  average  is  about  fifteen  days.  Great  danger  may  arise 
from  a  very  slight  case,  whether  it  is  recognized  or  not,  and 
these  mild,  oftentimes  unrecognized,  cases  are  likely  to  prevail 
when  diphtheria  is  epidemic.  The  habit  of  promiscuously  kiss- 
ing among  children  is  pernicious,  and  contributes  largely  to  the 
spread  of  diphtheria  and  other  infectious  diseases.  Malignant 
cases  are  readily  acquired  from  the  simplest  ones.  All  sore 
throats,  when  diphtheria  is  prevalent,  should  be  isolated  and 
carefully  treated ;  all  suspicious  cases  should  be  examined  bac- 
teriologically  and  the  greatest  precautions  taken,  even  when  the 
diphtheria  bacillus  is  not  found ;  but  where  the  staphylococcus 
is  demonstrated,  every  precautionary  measure  should  be  em- 
ployed, whether  in  families,  schools,  asylums,  or  hospital  wards, 
and  every  suspicious  case  instantly  set  apart  and  guarded.  If 
the  disease  shows  itself  in  several  instances  in  the  same  school, 
thorough  hygienic  measures  should  be  pursued  and  the  school 
closed  for  a  sufficient  time.  In  the  event  of  death  from  diphtheria 
the  body  should  be  wrapped  in  a  sheet  soaked  in  corrosive  sub- 
limate solution,  and  immediately  placed  in  a  sealed  casket ;  the 
funeral  should  be  strictly  private. 

A  patient  with  diphtheria  should  be  placed  in  a  large  room, 
free  from  all  hangings,  rugs,  and  unessential  furniture,  and  kept 
quietly  in  bed.  The  temperature  of  this  room  should  not  rise 
41 


642  THE    SPECIFIC    INFECTIOUS    DISEASES. 

above  68°  F.,  and  even  in  comparatively  cold  weather  free  venti- 
lation should  be  maintained  by  opening  the  windows,  or  those  in 
an  adjoining  room  if  drafts  are  feared.  An  open  fire  is  of  im- 
portance for  ventilation  as  well  as  warmth.  In  warm  weather 
a  lamp  burned  in  a  fireplace,  to  cause  an  upward  current  of  air, 
is  of  value.  The  bed  should  be  a  single  one,  with  opportunity 
to  approach  on  either  side.  All  discharges  from  the  patient 
should  be  thoroughly  disinfected.  Clean  cloths  or  absorbent 
cotton  are  to  be  used  instead  of  handkerchiefs  or  towels,  or  even 
tissue-paper,  and  everything  promptly  burned  after  using.  No 
one  should  be  allowed  in  the  room  except  those  immediately 
concerned  in  the  care  of  the  patient,  and  such  persons  demand 
special  treatment  and  strict  quarantine.  The  physician,  on  enter- 
ing the  room,  must  be  overclothed  with  garments  upon  both 
body  and  head,  which  should  be  disinfected  thoroughly.  He 
should  also  wash  his  face  as  well  as  his  hands  before  leaving  the 
room.  The  face-guard,  such  as  is  described  by  one  of  the 
authors  in  the  "Medical  News/'  1895,  is  of  value  to  prevent 
particles  of  infection  from  being  coughed  into  the  face — useful 
both  for  physician  and  nurse.  Those  in  constant  attendance  had 
better  spray  their  own  nostrils  and  throats  several  times  a  day 
with  some  cleansing  solution.  The  crowding  together  of  diph- 
theric patients  in  the  same  room  or  ward  is  to  be  deprecated,  as 
it  increases  the  virulence  of  the  disease.  Particular  attention 
should  be  given  to  the  throats  and  mouths  of  children,  especially 
to  the  teeth  and  tonsils. 

Local  Applications. — In  diphtheria  these  are  of  great  value,  and 
should  be  vigorously  but  carefully  employed,  though  they  must 
be  of  the  blandest,  and,  of  course,  omitted  in  very  young  children 
and  nervous  ones  who  become  alarmed.  The  objects  of  local 
treatment  are  to  remove  the  toxalbumins  and  destroy  the  bacilli, 
to  hasten  the  separation  of  false  membrane,  and  afford  relief 
to  the  dyspnea  arising  from  obstruction  in  the  larynx  by  the 
exudate.  Local  applications  are  useful  :  first,  as  germicides  ; 
second,  for  cleansing  purposes  ;  third,  to  dissolve  false  mem- 
branes ;  fourth,  to  allay  irritation.  They  should  be  applied  warm 
and  be  nonirritating. 

The  conclusions  of  Dr.  A.  Campbell  White  in  determining  how 
far  the  outlines  of  the  membrane  and  the  presence  of  the  bacilli 
are  influenced  by  local  measures  are  as  follows  :  (i)  The  prompt 
washing  of  the  air-passages  attacked  by  diphtheria  lessens  the 
duration  and  amount  of  the  diphtheric  membrane  ;  (2)  antiseptics 
of  sufficient  strength  to  be  germicidal  are  irritating  and  cause 
extension  and  persistence  of  the  false  membrane ;  (3)  they 


DIPHTHERIA.  643 

may  cause  systemic  poisoning  ;  (4)  spraying,  also  the  pernicious 
treatment  by  swabbing,  is  inefficient,  and  by  young  children  can 
not  be  endured  ;  (5)  frequent  cleansing  of  the  throat  and  nostrils 
with  a  bland  solution,  as  plain  warm  water  or  normal  salt  solution, 
is  easier  of  application,  more  agreeable  to  the  patient,  and  accom- 
plishes all  that  can  be  expected  of  any  antiseptic  solution. 

Loeffler  reports  excellent  results  from  the  use  of  his  so-called 
"toluol"  solution  for  the  local  treatment  of  diphtheria,  and  he 
regards  it  as  sufficient  without  other  specific  remedy.  He  claims 
a  low  mortality,  general  applicability,  whether  in  true  diphtheria 
or  mixed  infections,  and  absence  of  any  injurious  working,  con- 
siderable prophylactic  action  in  destroying  at  once  the  source  for 
the  spread  of  the  disease,  and,  finally,  its  cheapness.  This  solu- 
tion, as  recently  modified,  is  as  follows : 

Menthol, 20  gm.  dissolved  in  toluol  sufficient  to  make 

36  c.c. 

Absolute  alcohol, 60  c.c. 

Solution  of  ferric  sesquichlorid,      4  c.c. 

This  is  the  best  for  true  diphtheria  when  there  is  extensive 
putrefaction,  as  often  occurs  in  cases  of  mixed  infections. 

The  ferric  solution  may  be  substituted  with  advantage  by  2  or 
3  c.c.  of  creolin  or  one  minim  of  cresol,  absolute  alcohol  up  to 
100  c.c.  This  toluol  solution  will  keep  in  dark-colored  bottles 
with  glass  stoppers  for  months.  The  method  of  application  is  as 
follows  :  Superficial  mucus  being  removed  by  revolving  over 
the  membranes  a  large  swab  of  cotton,  a  fresh  swab  carrying  the 
solution  is  pressed  firmly  for  ten  seconds  against  the  affected 
spot,  and  this  repeated  until  the  whole  membrane  has  been 
treated.  Since  it  is  painful,  it  must  be  done  thoroughly  at  the 
first  attempt.  This  has  given  good  results  in  the  hands  of  many, 
used  once  or  twice  a  day,  seeming  to  check  the  spread  of  the 
membrane,  and  sequels  are  rarely  observed.  It  is  well  to  bear 
in  mind  that  local  pains  follow  the  application  of  Loeffler's  solu- 
tion, but  this  is  less  since  the  addition  of  the  menthol.  Guaiacol, 
applied  in  the  same  manner  as  Loeffler's  solution,  possesses  the 
same  virtues,  but  has  the  same  defects,  causing  pain  on  applica- 
tion. The  use  of  cocain  or  chloretone  previously  may  alleviate 
this.  A  large  number  of  local  applications  have  been  recom- 
mended, such  as  peroxid  of  hydrogen,  pyrozone,  hydrozone, 
mild  solutions. of  bichlorid  of  mercury,  etc.  Jacobi  recommends 
a  spray  containing  one  grain  of  corrosive  sublimate  to  the  pint, 
adding  a  dram  (5j)  of  table  salt.  Excellent  results  are  claimed 
by  Flick,  Judd,  and  others  in  the  local  use  of  calomel  in  powder, 
diluted  or  of  full  strength,  especially  in  the  nasal  form,  and  where- 


644  THE    SPECIFIC    INFECTIOUS    DISEASES. 

ever  the  membrane  can  be  reached.  A  number  of  cases  occur- 
ring in  Flick's  own  family,  as  well  as  in  those  of  his  friends,  have 
been  most  successfully  treated  by  this  means,  along  with  the  in- 
ternal administration  of  calomel  in  small  doses,  constantly  re- 
peated—  y^-0-  to  ^  of  a  grain  every  fifteen  minutes.  This  he 
regards  as  both  a  local  and  systemic  measure.  We  have  tried 
this  treatment  in  several  cases,  with  very  excellent  and  prompt 
effect.  Saturated  solution  of  borax  and  water  is  also  cleansing, 
but  common  table  salt,  one  dram  to  a  pint,  is  more  generally 
accepted.  Glycothymoline,  diluted  I  :  4,  is  both  cleansing  and 
cooling,  and,  not  being  poisonous,  can  be  used  copiously. 

A  solution  of  boric  acid  is  used  by  the  Germans.  Various  sol- 
vents for  the  mucous  membrane  are  occasionally  applied,  such  as 
pancreatin  or  papayotin,  I  :  20  in  water.  Trypsin  or  pepsin,  I  :  20, 
with  hydrochloric  acid  and  glycerin  and  caroid  in  powder,  have 
all  had  their  advocates.  Any  trustworthy  cleansing  solution  will 
suffice.  Applications  to  the  outside  of  the  throat  are  usually  use- 
less to  the  swollen  cervical  glands.  Lead-water  or  laudanum, 
belladonna,  ichthyol,  or  ice-bags,  however,  assist  in  relieving  pain. 
Ichthyol,  33  per  cent,  diluted  with  lanolin  is  perhaps  the  best  of 
external  remedial  agents,  and  ranks  in  value  next  to  cold  applica- 
tions. Vapors  of  various  sorts, — turpentine,  eucalyptus,  and  car- 
bolic acid, — sometimes  employed,  are  of  doubtful  efficacy.  Relief 
is  often  obtained  by  the  use  of  steam  generated  in  a  croup  kettle, 
and  directed  under  a  sheet  arranged  like  a  hood  over  the  patient's 
head — always  to  be  employed  in  intubation  cases.  Steam  thus 
applied  favors  suppuration,  aids  in  loosening  false  membrane, 
and  is  of  special  utility  in  the  laryngeal  forms.  Calomel  in 
powder,  diluted  or  of  full  strength,  especially  in  the  nasal  form 
and  wherever  the  membrane  can  be  reached,  is  the  oldest  of  the 
remedies,  and  has  been  used  since  the  time  of  Brettoneau.  As 
a  vapor  also — calomel  fumigation — it  is  employed  in  the  laryngeal 
variety.  (See  Membranous  Croup.) 

Great  care  and  judgment  must  be  exhibited  in  the  use  of  the 
local  measures,  especially  to  prevent  the  patient  becoming 
alarmed  or  excited,  and  lest  through  unskilful  manipulation 
the  disease  should  be  induced  to  spread,  or  ulcerated  or 
denuded  surfaces  be  thus  created,  which  become  avenues  for 
the  entrance  of  the  disease  elsewhere.  Where  the  nares  are 
nearly  occluded  by  a  thick  membrane  and  secretions,  they  may 
be  cleansed  by  a  cotton  swab  on  the  end  of  a  probe  dipped  in  a 
bland  cleansing  solution.  Irrigation  of  normal  salt  solution  is 
better  from  a  fountain  syringe  with  soft-rubber  nose-piece,  the 
child  wrapped  all  about  with  a  sheet,  to  restrain  the  movements, 


DIPHTHERIA.  64$ 

lying  on  its  side,  face  turned  down,  and  a  steady,  gentle  current 
run  into  the  upper  nostril,  the  solution  coming  out  of  the  lower 
nostril  by  gravity.  This  may  be  frequently  tried  until  the 
solution  comes  through  and  out  of  the  lower  nostril.  Then 
the  child  is  to  be  turned  on  its  other  side  and  the  process 
repeated.  If  irrigation  of  the  nose  produces  comfort  and  clears 
away  the  obstructions,  it  serves  an  admirable  purpose.  In  some 
cases,  where  the  nostrils  are  completely  occluded,  a  postnasal 
syringe  may  be  useful.  Care  should  be  taken,  however,  in 
practising  nasal  irrigation  that  too  much  force  be  not  used,  or 
the  solution  may  be  forced  into  the  Eustachian  tubes,  giving  rise 
to  much  pain  or  great  discomfort.  Where  there  is  hemorrhage,  if 
slight,  little  attention  need  be  paid  to  it,  but  if  severe,  astringent 
solutions  may  be  used — a  spray  of  pyrozone  is  perhaps  the 
cleanest  of  local  applications,  applied  to  the  bleeding  point  with 
an  atomizer,  or,  if  the  spot  be  seen,  on  a  pledget  of  cotton. 

Constitutional  Treatment. — The  object  of  constitutional  treat- 
ment is  to  combat  the  effects  of  toxins,  and  the  remedies  used 
have  been  selected  either  empirically  or  rationally.  It  is  hardly 
necessary  to  review  the  long  array  of  medicines  which  have  been 
offered  for  the  purpose  of  combatting  the  essential  poisons  of  diph- 
theria. Some  of  these  still  retain  the  confidence  of  many  wise 
men  and  able  observers.  The  internal  use  of  mercury  (calomel 
and  corrosive  sublimate)  has  still  its  stanch  advocates ;  this,  with 
the  local  use  of  tincture  of  chlorid  of  iron,  chlorate  of  potash, 
and  nascent  chlorin,  has  a  surprising  hold  in  the  treatment,  and 
is  second  only  to  antitoxin. 

The  internal  use  of  small  doses  of  calomel,  as  recommended 
by  Flick,  certainly  deserves  respectful  attention.  Flick  gives 
Y^j-  to  ^5-  of  a  grain,  alone  or  triturated  with  a  little  sugar  of 
milk,  every  fifteen  minutes,  combined  with  the  local  use  of 
calomel,  full  strength  or  triturated  one-third,  insufflated  every 
hour  or  two.  His  results  are  flattering,  and,  in  the  absence  of 
the  more  rational  and  efficient  remedy,  antitoxin,  the  method 
deserves  a  careful  trial.  In  the  discussion  of  his  second  paper 
an  important  point  was  brought  out,  namely :  That  a  large  pro- 
portion of  those  who  rely  on  antitoxin  in  the  treatment  of  diph- 
theria use  more  or  less  calomel  also  in  the  majority  of  cases. 
Judd  urges  similar  measures,  and  purges  his  patients  once  well 
with  the  calomel.  If  serious  evidences  manifest  themselves, 
destructive  changes  in  the  tissues,  sepsis,  etc.,  the  whole  depen- 
dence is  to  be  placed  on  constitutional  and  nutritive  measures 
and  not  on  any  specific  agent. 

A  powerful   agency  is  the  hypodermic  use  of  strychnin,  in 


646  THE    SPECIFIC    INFECTIOUS    DISEASES. 

doses  of  y^-jj-  to  ^j-  of  a  grain  to  a  one-year-old  babe,  repeated 
every  three  to  five  hours,  as  demanded.  Feeding  should  be  so 
full  as  to  be  almost  forced.  Alcoholic  stimulants  are  needed 
when  clearly  indicated,  but  are  credited  by  some  of  the  best 
clinicians  with  doing  much  harm  at  times.  The  indications  for 
stimulants  are  marked  prostration,  feeble  pulse,  dicrotism,  and 
a  weak  first  sound  of  the  heart. 

Rational  treatment  should  entirely  depend  upon  the  condition 
of  each  case,  and  should  be  employed  as  the  indication  may 
demand,  while  certain  measures,  such  as  disinfection  and  stimu- 
lants, are  always  in  order ;  the  employment  of  remedies  must 
require  judgment,  for  in  this  disease  it  is  often  a  fact  that  the 
treatment  becomes  a  routine,  and  no  adequate  regard  is  paid  to 
the  symptoms,  dangers,  or  sequels.  Because  the  study  of  this 
disease,  more  than  many  others,  has  become  the  property  of  the 
laity,  it  is  often  treated  at  home  by  the  relatives  for  some  time, 
and  when  failure  results,  the  physician  is  sent  for  and  meets  the 
case  under  deplorable  conditions.  We  think  it  proper,  for  con- 
venience, to  divide  the  treatment  into  different  stages,  as  follows  : 

First  Stage. — The  stage  of  incubation  or  bacteriologic  diph- 
theria— from  the  time  of  exposure  to  the  first  appearance  of  the 
exudate. 

Second  Stage. — The  stage  of  invasion — from  the  time  when 
the  exudate  first  appears  to  its  height. 

Third  Stage. — The  disease  proper,  where  the  diagnosis  is  cer- 
tain both  by  clinical  manifestations  and  bacteriologic  tests. 

Fourth  Stage. — The  graver  features  and  complications. 

Fifth  Stage. — The  decline — where  the  disease  has  pursued  a 
general  course,  indications  pointing  to  a  recovery,  the  patient's 
blood  assuming  immunization. 

Sixth  Stage. — The  sequelae. 

One  should  be  familiar  with  the  disease,  so  that  he  can  judge 
for  what  stage  the  treatment  is  indicated.  The  first  and  second 
stages  will  result  favorably,  if  the  recognition  is  prompt,  under 
any  careful  method  of  treatment.  It  is  in  the  third  and  fourth 
stages  where  the  judgment  of  the  physician  is  tested,  and  the 
result  ofttimes  depends  upon  his  clearness  in  noting  the  dangers 
and  how  to  prevent  or  cure  them.  Heart  failure  can  not  be 
remedied,  but  the  knowledge  that  it  is  impending  should  teach 
one  to  prevent  its  occurrence,  and  by  judicious  medicaments 
remove  the  first  symptoms  that  indicate  beginning  danger. 
Again,  where  diphtheria  is  seen  at  the  height  of  the  disease,  the 
question  may  pointedly  arise,  is  the  danger  diphtheria,  toxemia, 
or  septicemia,  and  it  is  utterly  useless  to  apply  antitoxin  in  a 


DIPHTHERIA.  647 

septic  case  if  no  attention  is  paid  to  the  septic  conditions.  If 
the  case  is  seen  in  the  fifth  stage,  it  is  still  necessary  to  apply 
treatment,  for  the  immunization  which  the  blood  of  the  patient  is 
undergoing  may  be  only  partial,  and  even  after  a  case  is  regarded 
as  cured  reinfection  may  take  place,  and  the  work  may  have  to  be 
repeated.  Often  has  this  been  seen  where  a  diphtheria  of  the 
faucial  variety,  treated  under  the  old  methods  and  pronounced 
cured,  has  returned  in  a  more  dangerous  form, — the  laryngeal, — 
necessitating  intubation  and  the  further  use  of  antitoxin  and  other 
treatment.  So  it  must  always  be  understood  that  diphtheria 
should  be  specifically  treated,  no  matter  under  what  conditions 
it  is  seen,  and  no  case  pronounced  cured  until  the  throat  is  free 
from  the  specific  bacteria  and  the  patient  well  of  any  complicating 
sequel.  It  is  well  to  follow,  as  a  general  rule,  the  following 
method  of  disinfection  : 

Disinfection. — When  a  child  has  been  relieved  from  imminent 
suffocation  or  has  received  an  injection  of  antitoxin  and  is  placed 
in  a  position  of  relief,  choose  two  rooms  in  the  house,  or,  if  this 
is  impossible,  one  large  room.  This  being  clean  and  heated, 
preferably  by  a  stove,  remove  the  child  to  it  without  delay.  The 
room  vacated  should  be  cleaned  at  once  by  burning  from  four  to 
eight  pounds  of  sulphur  in  it,  previously  closing  all  apertures, 
permitting  everything  to  remain  in  it  as  found,  and  keeping  the 
room  thus  closed  for  from  four  to  six  hours.  The  efficacy  of  the 
sulphur  vapor  can  be  increased  by  the  generation  of  a  little  steam 
in  the  room.  It  is  then  to  be  opened,  aired,  the  floor  and  wood- 
work scrubbed  with  soap  and  water,  and  afterward  washed  with 
sublimate  solution,  I  :  2000,  thoroughly  dried,  and  the  child 
returned  to  it,  the  same  procedure  repeated  in  the  first  apartment. 
Formaldehyd  generated  in  a  thorough  manner  is  as  efficacious 
as  sulphur,  and  is  now  in  general  use.  The  child  should  be 
changed  from  one  room  to  the  other  day  by  day,  so  that  while 
one  is  occupied  the  other  is  undergoing  the  process  of  cleansing. 
Choose  a  room  with  a  stove,  to  maintain  constant  temperature. 
On  the  stove  place  a  large  kettle  filled  with  boiling  water,  and, 
once  an  hour,  a  tablespoonful  of  the  following  mixture  : 

Eucalyptol, f^ij 

Acid,  carbol., 2|ij 

Ol.  terebinth.,      3XU- 

The  child  should  be  washed  once  daily  or  oftener,  and  dressed 
in  fresh  garments.  The  nourishment  and  medicines  are  to  be 
kept  out  of  the  room  and  only  brought  in  when  required.  The 
furnishing  is  to  be  the  merest  necessities — a  bed,  table,  chairs, 


648  THE    SPECIFIC    INFECTIOUS    DISEASES. 

and  stove.  Rigid  cleanliness  should  be  enforced  and  carried  out 
by  the  nurses.  Ventilation  should  be  of  the  freest,  with  caution  ; 
the  temperature  of  the  room  should  be  68°  F.  or  less,  the  win- 
dows or  those  in  the  adjoining  room  kept  open  constantly,  except 
in  extremely  cold  weather. 

Technic  of  Applying  the  Diphtheria  Antitoxin. — First,  choose  the 
antitoxin.  Second,  learn  accurately  its  strength.  Third,  learn 
how  to  apply  it  by  carefully  estimating  the  needs  of  the  individual 
case.  It  is  unnecessary  to  give  an  account  of  the  various  anti- 
toxins used  in  America ;  there  are  a  number  of  firms  who  manu- 
facture this  in  a  very  satisfactory  manner,  and  they  are  striving 
constantly  to  improve  their  methods  and  their  products.  In  the 
larger  cities  the  boards  of  health  manufacture  serums  for  their 
own  use  with  the  utmost  care,  most  of  which  have  been  shown 
to  be  of  excellent  quality. 

The  strength  of  the  serum  is  expressed  in  what  are  known  as 
immunizing  units.  This  denomination  originated  with  Behring, 
whose  first  or  normal  serum  was  of  such  strength  that  o.  I  c.c. 
of  it  would  protect  against  the  ten  times  fatal  dose  of  toxin  when 
simultaneously  injected  into  guinea-pigs.  Each  cubic  centimeter 
of  this  normal  serum  he  called  an  immunizing  uriit.  Later  it  was 
shown  that  the  strength  of  the  serum  could  easily  be  increased 
tenfold,  so  that  I  or  2  c.c.  of  the  serum  would  protect  a  guinea- 
pig  against  the  ten  times  fatal  dose.  Each  cubic  centimeter  of. 
this  stronger  serum  was  described  as  an  antitoxin  unit,  and,  of 
course,  contained  10  immunizing  units.  Still  later  it  was  shown 
that  the  limits  were  by  no  means  reached,  and  he  succeeded  in 
making  serums  as  much  as  300  times  the  normal  strength,  each 
cubic  centimeter  of  which  contained  300  immunizing  units,  or  30 
antitoxin  units,  and  at  present  antitoxin  is  made  of  which  each 
cubic  centimeter  contains  1000  immunizing  units. 

To  apply  the  antitoxin,  first  consider  the  technic  of  appli- 
cation ;  then,  the  dosage.  For  the  purpose  of  making  the 
injection  any  hypodermic  syringe  may  be  used,  if  of  satisfactory 
capacity.  The  one  we  prefer  is  a  special  syringe  made  for 
this  purpose,  with  a  rubber  packing,  having  a  capacity  of  five 
cubic  centimeters,  which  can  be  measured  accurately  by  a  screw, 
so  that  the  quantity  to  be  used  may  be  administered  at  one  in- 
jection. This  is  supplied  in  a  metal  case,  which  allows  the  whole 
to  be  sterilized  in  boiling  water  before  and  after  using.  A  good 
veterinary  hypodermic  syringe  is  satisfactoiy.  Another  excellent 
syringe  is  made  entirely  of  metal,  the  plunger  fitting  snugly,  the 
barrel  requiring  no  packing.  The  location  chosen  for  the  admin- 
istration is  usually  in  the  back,  between  the  scapulae,  on  each  side 


DIPHTHERIA.  649 

of  and  near  the  vertebral  column,  which,  being  in  a  sort  of  canal, 
is  protected  from  pressure  while  the  patient  is  lying  on  the  back  ; 
some  select  the  loins  or  sides  of  the  chest.  The  skin  should  be 
thoroughly  cleansed  by  means  of  alcohol  upon  sublimate  cotton 
or  gauze.  Immediately  after  the  injection  the  aperture  should 
be  closed  hermetically  with  iodoform  collodion.  The  syringe, 
before  each  using,  should  be  cleansed  thoroughly  by  means  of 
very  hot  water.  The  whole  operation  should  be  performed  with 
conscientious  aseptic  precautions.  We  have  never  met  with  any 
local  trouble  due  to  the  injection. 

The  Action  of  the  Antitoxin. — "  Experimental  evidence,  then, 
favors  the  theory  that  the  antitoxin  acts  through  the  agency  of 
the  living  bodies,  and  probably  in  the  sense  that  it  renders  the 
cells  tolerant  of  the  toxin.  It  is  not  to  be  expected,  then,  that 
the  effects  will  follow  the  injection  of  the  serum  with  the  same  cer- 
tainty and  precision  that  is  shown  in  chemic  reaction.  The  cells 
must  be  in  condition  to  respond  in  the  proper  way.  For  one 
reason  or  another  this  responsive  power  may  be  in  abeyance  ;  it 
may  be  weakened  by  intense  or  prolonged  resistance  of  the  diph- 
theria poison,  by  other  previous  or  recurring  diseases,  by  inher- 
ent weakness,  or  there  may  often  be  some  individual  idiosyncrasy 
which  hinders  the  response  of  the  cells  to  the  antitoxin.  There 
is  also  the  possibility  that  the  antitoxin  may  neutralize  the  effects 
of  certain  toxins  and  not  others  present  in  diphtheria.  Antitoxic 
serum  exerts  no  bactericidal  effects  upon  the  diphtheria  bacilli, 
though  when  administered  in  sufficient  quantity  early  in  the  dis- 
ease, it  arrests  the  spread  of  the  disease,  which  is  caused  by  the 
bacilli "  (Wm.  H.  Welch). 

Administration  and  Dosage  of  Antitoxin, — A  large  aggregate 
experience  with  antitoxin  has  led  to  clearly  defined  and  simple 
rules  for  its  administration.  A  clearer  conception  of  the  thera- 
peutic indications  for  the  remedy  and  the  recognition  that  there 
are  few  or  no  dangerous  after-effects,  and  but  few  and  rare  dis- 
agreeable results  following  an  injection  of  antitoxic  serum  in  doses 
ranging  from  lOOO  to  3000  immunizing  units  (4000  to  5000  units 
in  very  severe  cases),  have  led  to  the  employment  of  larger  and 
still  larger  doses ;  and,  where  repetition  is  found  needful,  at 
much  shorter  intervals  than  were  first  recommended. 

The  importance  of  inaugurating  serum  treatment  early,  recog- 
nized from  the  first,  has  grown  more  emphatic  by  accumulating 
evidence.  All  statistics  show  that  the  earlier  in  the  course  of 
the  disease  antitoxin  treatment,  or  any  other  treatment,  is  begun, 
the  better  are  the  results.  The  mortality  in  cases  so  treated, 
when  the  disease  is  in  its  incipiency  or  has  just  established  itself, 


650  THE    SPECIFIC    INFECTIOUS    DISEASES. 

is  very  small  (about  10  to  15  per  cent.),  and  in  cases  treated  late, 
say  from  five  to  eight  days,  may  range  as  high  as  30  or  40  per 
cent.  The  number  of  days  the  disease  has  apparently  progressed 
is  no  absolutely  reliable  criterion  of  the  stage  of  development  in 
the  individual  case.  This  applies  especially  to  the  formative 
period,  when  the  disease  is  frequently  more  or  less  masked,  and 
constitutes  one  of  the  several  reasons  why  antitoxin  treatment 
should  be  instituted  at  once  in  all  cases  which  excite  suspicion. 
In  the  clinical  management  of  all  such  cases,  and  of  all  acute 
anginas,  even  remotely  simulating  diphtheria,  a  full  curative  dose 
of  antitoxin  is  the  means  of  gaining  much  valuable  time  and  the 
saving  of  many  lives. 

Bacteriologic  examinations  are  of  totally  inadequate  clinical 
value  if  the  serum  injection  is  delayed  to  secure  a  report,  since 
too  much  time  is  thereby  lost  in  instituting  specific  treatment. 
Furthermore,  such  examinations  are  not  conclusive  independent 
of  the  clinical  manifestations  of  the  disease  ;  and,  again,  the 
great  majority  of  suspicious  cases  showing  negative  results  in  the 
laboratory  yield  with  equal  promptitude  to  the  serum  treatment. 

Antitoxin  treatment,  however,  is  of  value,  even  when  given 
late,  especially  in  the  laryngeal  variety.  A  thoroughly  reliable 
serum  administered  at  almost  any  period  of  the  disease,  will 
lessen  the  average  mortality  ;  it  must  be  accepted,  however,  as  a 
therapeutic  axiom  that  the  further  the  disease  has  progressed, 
the  greater  is  the  urgency  for  a  large  initial  dose  and  the  neces- 
sity for  repetition  of  the  dose  at  short  intervals — once,  twice,  or 
oftener  in  the  twenty-four  hours,  according  to  the  severity  of 
the  case. 

To  be  adequate,  a  curative  dose  of  antitoxic  serum  must  con- 
tain enough  immunizing  units  to  neutralize  perfectly  the  specific 
toxins  present  in  the  system.  When  this  is  done,  the  system  is 
rendered  immune  to  any  further  development  of  the  Klebs- 
LoefBer  bacilli,  and  the  disease  is  arrested.  If  the  initial  dose 
fails  to  accomplish  this,  the  disease  progresses  in  proportion  to 
the  degree  in  which  the  dose  has  fallen  short,  or  no  effect  at  all 
may  be  produced.  The  repetition  of  the  dose  or  its  increase  is 
then  instantly  indicated,  and  the  shorter  time  which  elapses  before 
such  repetition  is  made,  the  better  will  be  the  results. 

The  exact  therapeutic  indication,  as  far  as  concerns  the  num- 
ber of  immunizing  units  which  should  be  administered  in  any 
given  case,  can  not  be  determined,  since  there  is  no  possible 
means  of  estimating  the  quantity  and  virulence  of  the  absorbed 
toxins  ;  hence  the  imperative  need  of  a  sufficiently  large  initial 
dose. 


DIPHTHERIA.  65  I 

Doses  should  invariably  be  estimated  in  immunizing  units  and 
not  in  quantity  of  serum,  since  the  latter  is  only  the  vehicle. 
The  most  concentrated  serum — that  which  contains  the  largest 

O 

number  of  units  in  a  cubic  centimeter — is  the  most  desirable 
product  to  employ,  because  of  the  small  bulk  of  the  dose, 
diminished  irritation,  its  prompt  absorption,  speedy  effects,  and 
larger  percentage  of  cures. 

Immunizing  doses  for  healthy  persons  who  are  exposed  to  the 
contagion  need  seldom  exceed  500  units  in  adults,  and  200  or 
300  units  for  children,  depending  upon  circumstances,  degree 
of  exposure,  etc.,  and  are  operative  for  about  one  month  ;  three 
weeks  is  the  minimum. 

The  fear  once  attending  the  administration  of  immunizing  doses 
to  any  but  the  most  robust  children  has  been  found  groundless 
by  Merrill's  earlier  experience  in  the  Boston  City  Hospital, 
as  well  as  by  many  others.  Behring's  rule  is  to  give  100 
units  to  an  individual  of  about  120  pounds  bodily  weight. 
Rosenthal  gave  600  units  to  a  pregnant  mother  then  in  charge 
of  her  child  suffering  from  diphtheria.  She  was  subsequently 
confined  in  the  same  room  without  evil  effects.  He  now  gives 
to  each  person  where  exposure  is  constant  500  units,  and  if  the 
bacteriologic  test  shows  the  presence  of  the  specific  bacilli,  the 
case  belonging  to  the  first  stage,  a  full  curative  dose  of  1000 
units  is  invariably  given. 

A  curative  dose  should  be  1000  immunizing  units,  and  may, 
if  the  conditions  are  imperative,  be  as  high  as  3000  or  4000 
units  as  an  initial  dose.  The  age  of  two  years  should  be  the 
dividing  line,  below  that,  1000  units  are  sufficient;  above  that, 
1500  to  2000  units.  This  dose  of  1000  units  is  frequently 
sufficient  for  cases  seen  early,  in  the  second  stage  or  the  first 
day  of  the  second  stage.  In  well-developed  cases  showing 
more  or  less  malignancy,  in  laryngeal  cases,  and  in  the 
nasal  variety,  no  less  than  2000  units  should  be  given  as  an 
initial  dose ;  this  should  be  repeated  in  six,  twelve,  or  twenty- 
four  hours.  The  repetition  should  be  in  increasing  quantities. 
Thus,  if  the  initial  dose  is  1000  units  and  the  symptoms  are 
growing  worse,  the  second  dose  should  be  2000  units,  the  third 
dose  should  be  3000  or  4000  units,  and  so  on  in  increasing 
quantities  until  the  characteristic  reaction  is  obtained.  In  serum 
treatment  a  safe  rule  to  follow  is  increasing  dosage  if  the  case 
progresses,  and  never  a  smaller  dose  than  the  beginning  one. 
Some  operators  give  a  large  initial  dose  and  repeat  the  following 
doses  of  the  same  amount  (McCallom,  W.  H.  Park,  etc.).  If 
these  rules  are  followed,  either  the  large  initial  dose,  repeating 


THE    SPECIFIC    INFECTIOUS    DISEASES. 

the  same  dose,  or  the  gradual  increasing  dosage,  very  few  cases 
will  require  more  than  two  doses. 

In  making  the  injection  the  ordinary  aseptic  precautions  are  to 
be  taken  ;  this  applies  to  the  syringe  and  the  site  of  the  injection. 
The  former  is  easily  prepared  by  boiling,  and  the  lattter  by  the 
use  of  soap  and  water,  or  alcohol  soaked  on  sublimated  cotton 
or  gauze.  The  injection  can  be  made  at  any  point  of  the  body 
free  from  pressure — the  back,  sides  of  chest,  or  groins  ;  the 
interscapular  region  is  to  be  preferred :  the  patient  can  not 
there  witness  the  act,  and  will  be  less  apt  to  experience  fright. 

As  the  dose  of  antitoxin  should  always  be  given  in  units,  with- 
out regard  to  quantity,  it  would  be  well  for  manufacturers  to 
have  the  strength  of  each  cubic  centimeter  placed  conspicuously 
on  the  bottle.  The  contents  would  hardly  be  sufficient  if  it  were 
necessary  to  divide  the  dose  or  otherwise  modify  the  use  of  the 
remedy.  Therefore  each  of  the  bottles  should  be  labeled  :  500 
units  (for  immunizing  purposes)  ;  1000  units  (curative  for  mild 
cases)  ;  2000  units  (curative  for  severe  cases),  etc. 

The  following  rules  are  offered  as  regards  dose  :  In  the  first 
stage,  1000  units  ;  in  the  second  stage,  2000  units,  increasing  to 
4000  in  from  twelve  to  twenty -four  hours  if  the  case  progresses; 
in  the  third  stage,  3000  units,  increasing  possibly  to  6000  units 
in  conditions  of  great  urgency ;  in  the  fourth  stage,  3000  units 
and  20  c.c.  of  the  antistreptococcic  serum  may  also  be  used  if  the 
case  be  septic,  or  20  c.c.  of  antipneumonic  serum  if  the  specific 
manifestations  show  the  complication  of  pneumococcus  or  strep- 
tococcus *  ;  in  the  fifth  stage,  2000  units,  and  if  the  symptoms  of 
laryngeal  involvement  arise,  the  quantity  should  be  administered 
in  increasing  ratio,  as  in  case  third. 

Clinical  Manifestations  of  the  Diphtheria  Antitoxic  Serum. — 
Antitoxin  is  manifested  by  its — 

Effects  on  Pulse  and  Circulation. — In  the  faucial  variety  anti- 
toxin produces  a  marked  effect  in  about  eight  hours,  reducing  the 
tension  of  the  pulse  and  circulation  to  normal.  If  it  increase  again, 
it  is  an  indication  for  the  use  of  more  antitoxin.  In  laryngeal 
cases  the  pulse-rate  remains  high  throughout,  especially  in  those 
intubated,  and  the  indication  is  then  for  judicious  collateral  medi- 
cation. 

Effect  on  tJie  Temperature. — The  temperature  is  most  pro- 
foundly influenced  by  the  antitoxin  in  the  favorable  cases  of 
simple  diphtheria  ;  this  decline  is  from  any  elevation  to  the  normal. 

*  It  is  a  question  whether  we  have  as  yet  any  bacterial  remedies  capable  of  influenc- 
ing the  poisons  of  the  pneumococcus  or  the  streptococcus. 


DIPHTHERIA.  653 

Effect  on  Membrane. — On  the  diphtheric  membrane  the  effect 
is  most  marked,  limiting  its  continuance  oftentimes  to  twenty-four 
hours,  forming  a  separation  in  from  forty-eight  to  seventy-two 
hours,  when  the  red  line  surrounding  the  membrane  is  once  clearly 
seen,  and  over  which,  Rosenthal  asserts,  the  membrane  never 
spreads.  There  is  then  no  further  need  for  antitoxin. 

Effect  on  Laryngeal  Diphtheria. — (#)  Cases  not  requiring  oper- 
ation ;  (^)  intubation  cases. 

(a)  When  used  early  in  laryngeal  diphtheria,  it  prevents  the 
spread  of  the  membrane,  averts  asphyxia,  and  often  avoids  the  ne- 
cessity of  intubation  or  tracheotomy.  (£)  In  intubation  cases  anti- 
toxin in  a  great  measure  prevents  the  need  of  intubation  or  tra- 
cheotomy. When  intubation  is  demanded,  the  time  required  for 
wearing  the  tube  is  much  shortened,  and  tracheotomy  is  made 
unnecessary.  The  time  in  which  the  tube  is  worn  has  been  re- 
duced from  an  average  of  one  hundred  and  eighty-five  and  one- 
fourth  hours  to  one  hundred  and  sixteen  and  one -fourth  hours,  a 
reduction  of  sixty-nine  hours. 

The  Action  of  the  Antitoxin  in  Limiting  the  Duration  of  the 
Disease. — When  administered  early  in  simple  diphtheria,  all 
trace  of  the  disease  has  often  vanished  on  the  third  day.  In  the 
mixed  contagion  the  infection  is  antagonized  and  the  complica- 
tions are  to  be  treated  without  regard  to  the  existence  of  diph- 
theria. 

In  the  laryngeal  form  the  stenosis  disappears  on  the  third  day, 
unless  an  operation  is  demanded.  When  intubation .  has  been 
done,  the  tube  may  be  withdrawn  on  the  fourth  or  fifth  day.  In 
the  majority  of  cases  the  improvement  of  the  patient  begins 
obviously  and  at  once,  thus  lessening  the  probability  of  compli- 
cations. 

Local  applications  are  only  needed  for  the  purpose  of  cleanli- 
ness and  for  ridding  the  throat  of  the  specific  organisms,  which 
may  be  a  source  of  danger  to  others. 

Unfortunately,  though  the  power  of  the  antitoxin  is  great,  it 
is  by  no  means  a  cure-all,  and  complications  may  arise  demand- 
ing prompt  and  ample  attention.  Disturbances  of  the  heart, 
lungs,  or  kidneys  must  be  treated  as  they  arise,  without  regard 
to  the  precedent  diphtheria. 

The  presence  of  the  bacilli  in  the  throat  is  not  markedly 
affected  by  the  antitoxin,  and  these  persist  long  after  convales- 
cence, just  as  in  other  forms  of  treatment.  It  is  important  to 
make  frequent  test  cultures  to  determine  this  fact. 

The  Influence  of  Antitoxin  on  the  Mortality  Records. — The 
mortality  records  in  all  large  cities  are  now  preserved  with  such 


654  THE    SPECIFIC    INFECTIOUS    DISEASES. 

care  that  reliable  conclusions  are  to  be  drawn  thence.  It  has 
been  shown,  without  peradventure,  taking  all  the  various  statis- 
tics into  consideration,  that  the  use  of  the  antitoxic  serum  has 
enormously  lessened  the  death-rate. 

There  remains,  then,  to  consider  one  important  point,  the 
effect  of  antitoxin  upon  the  various  complications.  If  certain 
organs  have  begun  to  be  damaged  by  the  poison,  or  where  they 
were  unsound  previously,  always  difficult  to  determine,  then  the 
disease  process  may  not  be  stopped  by  antitoxin.  It  is  more  than 
probable,  however,  that  an  early  and  adequate  dose  of  antitoxin 
will  check  or  limit  the  mischief  thus  begun  or  emphasized  by  the 
diphtheria.  It  must  be  borne  in  mind,  too,  that  by  the  curative 
effects  of  the  serum  many  cases  survive  to  acquire  complications, 
which  had  otherwise  succumbed  early.  Dana  has  given  a 
thorough  consideration  of  the  subject  of  diphtheric  palsies  and 
the  use  of  antitoxin.  His  conclusions  are  that,  while  the  diph- 
theric palsies  are  not  increased  by  the  use  of  antitoxin,  the  fact 
that  they  are  not  much  affected  nor  stopped  shows  that  the 
antitoxin,  however  effective  as  a  whole,  is  not  given  in  sufficient 
doses  to  prevent  the  specific  effect  of  the  diphtheria  on  the 
nervous  tissues.  Nevertheless,  he  admits  that  while  the  anti- 
dotal action  of  antitoxin  is  incomplete  so  far  as  the  nervous 
centers  are  concerned,  it  is  sufficiently  powerful  in  a  large 
number  of  cases  to  prevent  serious  destruction  to  the  organism. 
Destructive  tissue  changes  are  not  to  be  influenced  by  any  spe- 
cific ;  we  must  depend  for  their  removal  and  repair  on  rational 
and  constitutional  treatment  and  by  meeting  the  special  symp- 
toms as  best  we  can. 

Pneumonia  is  a  serious  and  frequent  complication  of  diphtheria 
in  children.  The  appearance  of  the  antipneumonic  serum  gives 
hope  of  preventing  this,  and  where  the  disease  has  already  pro- 
gressed, of  hastening  resolution  to  a  favorable  termination. 
Nothing  in  the  way  of  local  treatment  will  avail  in  broncho- 
pneumonia  following  diphtheria.  Antiseptic  vapors  are  value- 
less, as  their  germicidal  properties  can  not  reach  the  seat  of  dis- 
ease in  the  terminal  bronchi  and  air-cells.  Inhalations  of  oxygen, 
repeated  frequently  on  demand  by  symptoms,  are  useful  partly 
as  heart  stimulants  and  partly  to  reinforce  the  crippled  lung. 
The  use  of  the  cold  pack  is  not  to  be  recommended.  Some 
cases  may  be  benefited  thereby,  while  in  others  it  is  very  badly 
borne.  Counterirritation  with  some  stimulating  liniment  con- 
taining germicidal  properties,  as  the  oil  of  cinnamon,  gaultheria, 
and  eucalyptus,  gives  some  relief.  Each  case  must  be  treated 
with  a  view  to  preventing  rather  than  to  treating  this  complica- 


DIPHTHERIA.  655 

tion,  and  while  in  some  the  cold  pack  is  of  undoubted  utility,  in 
others  warm  poultices  act  better,  while  in  yet  others  a  liniment 
with  a  cotton  jacket  seems  best.  The  antipneumonic  serum, 
with  judicious  collateral  treatment,  offers  more  hope  than  any 
treatment  In  intubation  cases  it  is  a  useful  precaution  to  keep 
the  foot  of  the  bed  raised  a  foot  higher  than  the  head,  to 
encourage  the  draining  away  of  discharges.  Drugs  to  affect  the 
heart  as  well  as  temperature  are  to  be  used,  such  as  strychnin, 
caffein,  ether,  nitroglycerin,  alcohol,  and  digitalis. 

Complications  and  Sequelae. — The  most  frequent  and  by 
far  the  most  important  complications  and  sequelae  of  diphtheria 
are  the  various  forms  of  paralyses.  These  occur  much  less  fre- 
quently in  children  than  in  adults.  Paralytic  symptoms  may 
occur  early  in  the  disease,  but  usually  come  on  about  the  third 
or  fourth  week,  and  are  independent  of  the  general  condition  of 
the  child.  (See  Neuritis.) 

The  intensity  of  the  attack  of  diphtheria  is  scarcely  ever  an 
index  of  the  extent  or  severity  of  the  paralysis,  nor  is  the 
severity  of  the  palsy  to  be  inferred  from  the  amount  of  membrane 
in  any  given  case,  for  the  milder  forms  of  laryngeal  diphtheria 
are  frequently  followed  by  paralytic  symptoms,  and  the  propor- 
tion varies  in  different  epidemics. 

The  commonest  form  of  paralysis  is  that  which  affects  the 
muscles  of  the  soft  palate  and  the  muscles  of  deglutition  ;  evi- 
dence of  this  form  of  paralysis  is  manifested  by  a  nasal  intonation 
of  the  voice,  uncertain  speech,  dysphagia,  and  regurgitation  of 
liquids  through  the  nose. 

Occasionally  we  have  seen  motor  paralysis  of  the  ocular 
muscles,  causing  strabismus  and  ptosis,  also  at  times  involving  the 
muscles  of  accommodation. 

Less  commonly  a  multiple  form  of  peripheral  neuritis  occurs. 
In  most  cases  it  begins  with  the  muscles  of  the  palate  and  those 
concerned  in  the  act  of  deglutition,  and  gradually  extends  to  one 
or  more  extremities,  the  degree  of  paralysis  often  varying  in  dif- 
ferent groups  of  muscles. 

The  most  serious  form  of  palsy  is  that  found  in  connection 
with  the  heart.  Heart  failure  may  occur  at  any  time  in  the 
attack  or  during  convalescence,  owing  to  the  effect  of  the  toxins 
upon  the  nerves  and  the  muscle  of  the  heart.  (See  Myo- 
carditis.) 

Albuminuria  of  diphtheria  is  not  to  be  regarded  as  an  unfavor- 
able sign  unless  albumin  is  found  in  considerable  quantity  in  the 
urine  and  associated  with  the  more  malignant  forms  of  the  dis- 
ease. 


656  THE    SPECIFIC    INFECTIOUS    DISEASES. 

The  most  serious  complication  involving  the  lungs  is  broncho- 
pneumonia,  as  seen  in  young  children. 

Pericarditis,  endocarditis,  and  meningitis  are  rare,  and  are 
observed  only  in  septic  cases  of  the  severer  forms. 


TRACHEOTOMY. 

This  classic  operation  for  the  relief  of  laryngeal  stenosis  has 
been  slowly  superseded  by  that  of  intubation,  and  in  diphtheria 
especially,  since  the  advent  of  antitoxin,  it  has  been  all  but 
abandoned  in  America. 

From  being  the  only  clearly  indicated  and  rational  procedure, 
its  position  became  one  of  uncertainty,  and  in  intubation,  as  a 
rival,  this  hesitation  was  an  unfortunate  one,  as  it  seemed  to 
affect  the  operator,  and,  in  a  choice  of  methods,  the  easier  one 
being  accepted,  tracheotomy  has  been  given  second  place,  much 
to  the  injustice  of  its  value,'  and  with  a  plain  disregard  of 
definite  indications. 

For  this  reason,  and  while  the  operation  of  intubation  has  be- 
come the  general  one,  it  is  well  to  always  retain  the  operation  of 
tracheotomy  in  our  list  of  remedies,  and  to  place  it  upon  a  posi- 
tive footing  by  briefly  enumerating  the  conditions  which  may 
necessitate  this  operation,  maintaining  this  assertion  that  intuba- 
tion and  tracheotomy  are  not  rivals  in  any  sense  of  the  word, 
but  are  separate  and  distinct  proceedings,  which  have  certain 
well-defined  indications  for  their  special  use.  The  operation  of 
tracheotomy  then  is  indicated  : 

1.  In  those  accidental   cases  in  which  the  membranes  have 
been  forced  down  the  larynx  by  attempts  at  intubation. 

2.  In  those  cases  where  the  membranes  are  too  extensive  and 
are  not  to  be  reached  or  relieved  by  the  intubation  tubes. 

3.  In  those  cases,  previously  intubated,  where  there  has  been 
a  continuous  formation  of  membranes  reaching  below  the  tube. 

4.  In  those  cases  where  the  membranes  have  become  loosened 
in  the  larynx,  and  where  the  choice  lies  between  intubation  and 
tracheotomy,  the  latter  is  free  from  danger,  for  by  the  introduc- 
tion of  a  tube  the  membranes  may  be  forced  down  still  further 
into  the  larynx,  causing  asphyxia,  and  then  necessitating  prompt 
tracheotomy. 

While  the  operation  of  tracheotomy  means  an  opening  in  the 
trachea,  the  general  term  includes  all  those  operations  which 
open  the  respiratory  channel  between  the  thyroid  cartilage  and 
the  sternum. 

When  the  operation  is  decided  upon,  the  next  point  is  to  elect 


TRACHEOTOMY.  657 

the  site  ;  this  in  a  measure  depends  upon  the  time  devoted  to  it 
and  the  urgency  of  the  case. 

When  haste  is  indicated,  everything  must  give  way  to  the 
rapidity  with  which  relief  must  be  afforded  ;  hence  the  isthmus 
of  the  thyroid  may  be  divided  or  a  large  vein  cut,  and  the  hem- 
orrhage may  enter  the  trachea  with  the  air,  but  this  hemorrhage 
can  be  checked  and  such  chances  must  always  be  taken. 

A  rule  to  follow  is  to  make  the  incision  as  far  down  as  possi- 
ble, to  tie  the  isthmus  in  two  places,  or  clamp  the  tissues  with  a 
hemostat  and  open  the  windpipe. 

While  the  operation  appears  simple  to  describe  and  equally 
simple  to  perform  upon  the  cadaver,  it  is  a  very  trying  one  when 
circumstances  demand  haste.  In  all  cases  it  is  well  for  the  sur- 
geon to  come  prepared  for  such  emergencies.  Besides  the  nec- 
essary instruments,  a  portable  electric  light  with  a  forehead 
reflector  is  a  most  useful  adjunct.  The  necessary  instruments 
are  the  knives,  scissors,  tenacula,  hemostats,  needles,  ligature, 
retractors,  and  trachea  tubes.  Various  kinds  of.  tubes  are  to  be 
had,  but  even  if  the  tubes  are  not  at  hand,  improvised  retractors 
will  suffice,  which  can  be  made  of  two  common  hairpins,  bent  at 
an  angle,  while  the  pointed  ends  can  be  fastened  to  a  piece  of 
tape  ;  the  bent  crowns  can  be  placed  on  each  side  of  the  open- 
ings and  thus  hold  the  wound  apart,  and  free  access  of  air 
admitted.  Even  if  these  are  not  procurable,  a  stitch  can  be 
put  on  each  side  of  the  opening,  through  skin  and  tissues,  into 
the  trachea,  and  the  long  ends  made  to  meet  at  the  back  of  the 
patient  and  then  tied.  The  patient  can  thus  be  relieved  until  a 
tube  is  procured. 

When  operating,  the  head  and  neck  should  be  stretched  over 
a  pillow  or  sand-bag.  Cocain  or  chloretone  can  be  used  locally, 
unless  the  patient  is  unconscious.  An  incision  in  the  middle  line 
is  made  from  the  cricoid  for  five  or  seven  centimeters  downward. 
After  cutting  the  skin  the  muscles  are  separated,  all  hemorrhage 
is  stopped,  the  trachea  is  steadied  and  brought  forward  by  means 
of  a  tenaculum  ;  it  is  then  incised  by  means  of  a  sharp  knife,  care 
being  taken,  first,  to  cut  upward,  and,  second,  to  guard  against 
injuring  the  posterior  wall  by  a  sudden  cough,  due  to  the  ingress 
of  air  or  blood. 

At  first  there  is  a  violent  and  irregular  respiratory  movement, 
with  a  sucking-in  of  air  and  blood  and  expulsion  of  mucus, 
membranes,  or  the  like,  so  that  care  must  be  at  all  times  exhibited. 
After  the  respiration  has  resumed  a  more  normal  quality,  atten- 
tion should  be  paid  to  the  parts  exposed  :  it  may  be  necessary  to 
enlarge  the  opening  for  the  removal  of  shreds  or  membranes. 
42 


658  THE    SPECIFIC    INFECTIOUS    DISEASES. 

If  the  operation  is  done  secondary  to  intubation,  the  technic  is 
the  same,  but  the  process  is  easier,  for  here  the  intubation  tube 
may  remain  in  situ  and  act  as  a  guide  during  and  until  the 
operation  is  finished. 

The  after-treatment  requires  the  presence  of  a  trained  nurse, 
and  an  equal  amount  of  skill  and  knowledge  to  perform  as  the 
operation  itself. 

More  deaths  can  be  ascribed  to  the  lack  of  after-treatment 
than  to  any  defects  in  methods  or  conditions.  It  is  for  this 
reason  that  intubation  has  become  such  a  favorite  and  will  always 
be  used  when  possible. 

After  the  patient  has  been  placed  in  a  position  of  relief,  it  is 
well  to  emphasize  the  importance  or  care  in  the  further  treat- 
ment and  what  other  methods  are  to*  be  pursued.  As  the  chief 
danger  is  caused  by  the  entrance  of  foreign  substances  directly 
into  the  lungs,  and  as  air  unmoistened  and  too  cold  acts  as  an 
irritant,  it  is  well  to  keep  the  room  judiciously  warmed  :  a  tem- 
perature of  80°  F.  is  not  too  high.  The  bed  should  be  so 
arranged  that  the  air  can  be  brought  to  the  child  moist  and  free 
from  deleterious  influences. 

A  measure  most  valuable  and  easily  applied  is  to  keep  some 
absorbent  gauze  moistened  with  a  weak  solution  of  bichlorid 
constantly  in  contact  with  the  wound  and  over  the  opening  of 
the  tube.  The  greatest  care  should  be  exercised  in  the  cleanli- 
ness of  the  tubes,  and  they  should  be  sterilized  frequently. 

Medicinal  treatment  should  be  pursued  with  the  same  regu- 
larity as  regards  tonics,  stimulants,  foods,  and  the  like. 


INTUBATION  OF  THE  LARYNX. 

In  the  course  of  laryngeal  diphtheria  a  growth  of  the  exudate 
may  become  so  obstructive  as  to  require  artificial  means  to  intro- 
duce air  into  the  lungs.  We  are  presented  with  two  alterna- 
tives :  one  just  described  -as  tracheotomy,  by  opening  the  wind- 
pipe below  the  seat  of  obstruction,  and  the  other,  the  bloodless 
operation  of  intubation,  consisting  of  the  introduction  of  a  tube 
through  the  mouth  into  the  larynx,  passing  the  seat  of  obstruc- 
tion, and  maintaining  egress  and  ingress  of  air  through  the  tube 
left  in  place. 

For  the  proper  treatment  of  such  conditions  it  is  essential  for 
the  operator  to  be  always  prepared  to  be  familiar  with  and  to 
practise  either  operation,  and  while  he  may  undertake  and  per- 
form the  operation  of  intubation,  he  should  at  the  same  moment 


INTUBATION  OF  THE  LARYNX. 


659 


be  ready  to  follow  this  attempt  by  tracheotomy  should  the  case 
demand  it. 

Laryngeal  intubation  is  universally  recognized  as  a  life-saving 
operation,  and  the  honor  of  its  creation  belongs  to  Joseph 
O'Dwyer,  of  New  York.  The  history  of  intubation,  like  that 
of  every  other  successful  procedure  in  medicine,  bears  repetition. 


FIG.  41. — METHOD  OF  FEEDING  CHILD  AFTER  INTUBATION. 

Hippocrates  attempted  intubation  by  the  use  of  a  catheter.  In 
1857  Loiseau  attempted  catheterization  of  the  larynx  as  a  treat- 
ment for  croup,  and  in  1858  Bouchut  devised  tubes  for  perma- 
nent catheterization,  but  his  tubes  were  seldom  applied  and  his 
method  of  "  tubage  "  was  lost  in  oblivion. 


66O  THE    SPECIFIC    INFECTIOUS    DISEASES. 

On  May  23,  1888,  O'Dwyer  ("  Proceedings  of  the  Philadelphia 
County  Medical  Society,"  vol.  ix,  1888)  presented  a  paper  on 
"  Intubation  Tubes  "  and  described  the  different  stages  traversed 
by  him  until  he  had  finished  the  tubes  now  in  use. 

O'Dwyer's  creation  was  absolutely  original,  and  he  devised 
and  perfected  each  tube,  with  the  necessary  instruments  for 
their  use,  and  by  his  matchless  ingenuity  and  untiring  energy 
placed  the  operation  of  intubation  upon  the  certain  foundation 
which  it  now  occupies. 

O'Dwyer's  instruments  consist  of  a  set  of  six  tubes,  with  a 
like  number  of  obturators,  an  introducer,  an  extractor,  a  mouth 
gag,  and  a  gage. 

The  tubes  are  so  shaped  that  they  approximately  fit  the  larynx, 
being  somewhat  bulbous  at  their  lower  third,  and  are  graded  in 
size  by  the  gage,  indicating  the  ages  of  those  for  whom  they  are 
to  be  used.  It  is  essential,  however,  to  take  into  consideration 
the  size  of  the  child,  as  frequently  a  much  larger  or  smaller  tube 
may  be  required  than  is  indicated  by  the  gage,  and  thus  some 
judgment  should  be  exercised  in  the  choice  of  the  tube. 

It  is  also  well  to  remember  that  in  certain  stages  of  the  dis- 
ease the  parts  may  be  swollen  or  occluded  by,  a  deposit  of 
pseudomembranes  and  that  the  safety  of  the  operation  may 
require  a  much  smaller  tube  than  is  indicated  by  age  scale,  the 
regular  tube  being  too  large  for  the  affected  larynx,  and  accidents 
often  arise  by  forcing  the  membranes  down  into  the  larynx, 
causing  asphyxia. 

It  is  important  in  using  the  O'Dwyer  tubes  to  have  them 
thoroughly  cleansed  after  each  using,  and,  better,  regilded,  thus 
preventing  any  element  of  contagion  ;  in  every  new  case  be 
certain  always  to  use  a  new  tube.  Even  should  the  tube  be 
returned  from  the  gilder  and  be  practically  new,  it  will  always 
be  well  to  cleanse  it  thoroughly  by  boiling,  for  frequently  for- 
eign substances  adhere  to  the  new  tubes.  After  boiling,  dry 
by  passing  corrosive  cotton  through,  insert  the  thread,  and  then 
the  tube  is  ready  for  use. 

Method  of  Introducing  an  Intubation  Tube. — Two  assis- 
tants are  required,  neither  of  whom  need  be  skilful.  The  child, 
previously  wrapped  in  a  blanket  or  sheet  with  its  arms  covered,  is 
placed  on  the  lap  of  the  one  assistant,  in  a  sitting  position,  so  that 
its  legs  are  held  firmly  between  the  assistant's  knees.  The  pa- 
tient's arms  are  held  firmly  to  its  sides  by  the  hands  of  the  assis- 
tant or  nurse,  in  such  a  way  as  to  steady  the  trunk,  and  in  no 
way  to  interfere  with  the  respiration  of  the  child. 

The  second  assistant  stands  behind  the  child,  steadies  the  head, 


INTUBATION  OF  THE  LARYNX. 


66 1 


and  holds  it  in  correct  position.  The  proper  attitude  is  thus 
obtained  :  the  first  assistant  draws  the  head  up  so  that  the  child 
seems  to  hang  from  the  top  of  its  head  ;  in  this  position  only  is 
it  practicable  accurately  to  introduce  the  tube,  and  this  attitude 
should  be  firmly  maintained  during  its  insertion. 

The  tube,  with  the  silk  thread  clear  and  free,  is  attached  to 
the  introducer.      The  gag  is  inserted  into  the  left  angle  of  the 


FIG.  42. — METHOD  OF  INTRODUCING  THE  O'DWYER  TUBE  IN  INTUBATION. 


mouth,  which  is  opened  as  widely  as  possible,  due  care  being 
observed  to  prevent  laceration  of  the  soft  parts. 

The  attempt  at  introduction  can  now  be  made,  and  should  be 
done  quickly,  and  during  expiration,  for  while  the  attempt  is  being 
made  there  is  complete  arrest  of  respiration,  and  should  mem- 
branes be  dislodged,  inspiration  may  draw  them  further  down  into 
the  trachea  or  bronchi.  Several  short  attempts  are  always  better 
than  a  single  prolonged  one,  and  should  there  be  a  cessation  of 


662  THE    SPECIFIC    INFECTIOUS    DISEASES. 

respiration  or  incomplete  relief,  the  tube  should  be  immediately 
withdrawn  and  a  new  attempt  may  follow.  Never  use  force. 
Very  little  power  is  required,  except  in  cases  of  subglottic 
stenosis,  where  quite  a  little  force  is  needed  to  overcome  the  spas- 
modic contraction.  The  index-finger  of  the  left  hand  is  the 
guide  in  the  act  of  introduction.  This  is  passed  far  back  into 
the  larynx,  then  brought  forward  until  the  upper  border  of  the 
cricoid  cartilage  is  felt,  directly  in  front  of  the  epiglottis,  which 
is  to  be  elevated  by  the  tip  of  the  finger.  The  tube,  with  the 
silk  thread  looped  over  the  little  finger  of  the  right  hand,  is 
passed  along  the  palmar  surface  of  the  index-finger,  by  which  it 
is  guided  into  the  larynx  ;  the  handle  of  the  introducer  is  drawn 
around  so  that  it  stands  in  the  median  line.  In  this  way  the 
tube  is  brought  into  the  correct  position,  after  which  it  is  pushed 
off  the  introducer  by  the  trigger  attached  to  the  handle,  and  is 
simply  dropped  into  the  larynx,  or  the  tube  may  be  dislocated 
from  the  obturator  while  removing  the  latter,  and  steadied  by 
placing  the  finger  on  its  head,  and,  after  the  removal  of  the 
introducer,  pressed  gently  down  into  the  box  of  the  larynx. 

When  it  is  certain  that  the  tube  is  in  position  and  the  patient 
breathes  properly,  the  silk  thread  is  cut  and  withdrawn,  care 
being  taken  not  to  pull  the  tube  along  with  it.  This  is  done  by 
placing  the  index-finger  again  gently  upon  the  head  of  the  tube. 

Should  there  be  evidence  of  loosened  membranes,  or  should 
the  relief  be  not  marked,  or  if  there  is  any  suspicion  that  the 
operation  is  incomplete,  as  when  the  tube  is  introduced  into  the 
esophagus,  the  silk  thread  should  be  allowed  to  remain,  espe- 
cially when  prompt  extubation  is  required.  It  is  always  well  to 
allow  the  thread  to  remain  at  least  twenty  or  thirty  minutes  or 
longer,  until  the  operator  is  thoroughly  satisfied  of  the  complete- 
ness of  the  procedure. 

That  the  tube  is  correctly  placed  is  evidenced  by  the  previously 
stridulous  or  rasping  breathing  giving  way  to  a  hissing  breathing 
sound,  followed  by  a  paroxysm  of  coughing,  excited  by  the  irri- 
tation of  the  tube,  and  by  the  prompt  relief  of  the  dyspnea. 

The  coughing  is  an  extremely  good  symptom,  and  is  the  most 
thorough  and  sure  means  of  getting  rid  of  the  accumulating 
mucus  and  loosened  membranes. 

The  dangers  of  intubation  are  :  The  crowding-down  of  the 
loosened  membrane  into  the  larynx,  thus  causing  asphyxia  and 
necessitating  prompt  tracheotomy  ;  or  the  making  of  a  false 
passage  by  using  too  much  force  and  working  at  an  angle  of  the 
mouth  instead  of  keeping  the  median  line  ;  or  producing  asphyxia 
by  prolonged  or  injudicious  attempts  at  introduction. 


INTUBATION  OF  THE  LARYNX.  663 

There  are  also  dangers  in  performing  extubation.  The  tube 
may  be  pushed  down  into  the  trachea  by  too  firm  a  pressure 
upon  the  head  of  the  tube  of  the  extractor,  or  injuries  to  the 
soft  tissues  of  the  larynx  by  missing  the  opening  of  the  tube 
and  dilating  the  extracting  forceps  too  widely  and  forcibly  with- 
drawing. Their  prevention  is  self-evident. 

After-treatment. — After  intubation,  as  soon  as  practicable, 
give  the  patient  something  to  drink — water,  milk,  wine,  as  the 
case  may  need.  Permit  the  child  to  hold  the  glass  or  cup  and 
serve  itself.  Generally  the  drink  causes  coughing,  and  thus 
mucus  and  membranes  are  frequently  brought  away. 

Vomiting  very  commonly  follows  intubation,  the  child  by  this 
means  attempting  to  dislodge  the  tube,  and  in  this  it  sometimes 
succeeds,  thereby  necessitating  a  repetition  of  the  whole  pro- 
cedure. Care,  therefore,  must  be  used,  and  in  the  act  of  cough- 
ing or  vomiting  the  child  should  not  be  allowed  to  lie  upon  its 
face  ;  nor  should  it  be  held  over  the  nurse's  shoulder  face  down- 
ward, for  in  either  position  very  slight  exertion  might  cause  it  to 
expel  the  tube.  After  a  while  the  child  becomes  quiet,  respira- 
tion assumes  a  more  normal  character,  the  pallid  lips  take  on  a 
healthy  hue,  relief  becomes  manifest,  and  a  quiet  sleep  follows. 

In  cases  complicated  by  grave  pulmonary  lesions  the  relief 
obtained  by  intubation  is  but  transitory,  but  life  can  thus  be 
prolonged  so  that  suitable  remedial  agents  can  be  administered. 

As  intubation  is  simply  a  means  to  relieve  stenosis,  the  further 
treatment  follows  the  same  category  as  is  pursued  in  treating 
diphtheria. 

As  is  well  known,  bronchopneumonia  is  frequently  a  compli- 
cation of  the  laryngeal  variety  of  diphtheria  ;  therefore  the 
further  treatment  must  be  rather  that  of  the  preventive  type. 
Again,  intubated  cases  are  more  liable  to  heart  failure,  and  due 
care  and  foresight  must  be  directed  to  this  possibility.  It  is 
therefore  well,  as  a  routine  treatment,  to  administer  cardiac  tonic 
remedies,  even  if  at  the  time  there  is  no  indication  for  their  use. 
A  very  useful  prescription  to  be  given  during  intubation  consists 
of  tincture  of  digitalis,  combined  with  strychnin  and  either  the 
carbonate  or  aromatic  spirit  of  ammonia,  using  syrup  of  tolu  as 
a  vehicle.  Caffein  often  acts  even  better. 

While  intubated  cases  frequently  get  along  well  enough  in  their 
ordinary  surroundings,  the  air  being  moistened  in  the  natural  way 
before  being  inspired,  it  is  often  necessary  to  place  the  patient  in 
a  specially  moistened  atmosphere.  An  improvised  tent  can  easily 
be  rigged  up  in  any  household  by  means  of  an  umbrella  and  one 
or  two  sheets.  (See  Fig.  38,  Improvised  Croup  Tent.) 


664  THE   SPECIFIC    INFECTIOUS    DISEASES. 

Steam  can  be  led  under  this  canopy  from  a  special  croup 
kettle  or  from  any  steam  kettle.  Such  a  tent  will  be  found  very 
useful  if  complications  exist  or  if  the  case  is  a  prolonged  one, 
necessitating  frequent  and  prolonged  intubation.  Of  far  more 
difficulty  is  the  administration  of  food,  and  here  the  ingenuity  of 
the  physician  is  frequently  taxed.  In  the  very  young,  where 
nothing  but  fluids  are  taken,  this  is  overcome  by  having  the  head, 
in  the  act  of  swallowing,  placed  lower  than  the  body. 

This  can  also  be  tried  in  older  children,  where  there  is  difficulty 
in  swallowing  in  the  sitting  position. 

Often  food  is  refused  in  any  shape,  and  water  is  urgently  de- 
manded. It  is  safe  to  give  any  quantity  of  water,  and  where 
there  is  difficulty  in  swallowing,  small  pieces  of  ice  may  be  taken. 
Many  children  subsist  for  one  or  two  days  on  nothing  else  but 
small  pieces  of  ice.  Frequently  it  is  found  that  semisolids  are 
swallowed  more  easily  than  liquids  ;  then  may  be  given  corn- 
starch,  wine-jelly,  oatmeal  gruel,  eggs,  and  the  like. 

The  entrance  of  food  into  the  bronchi  through  the  tube  is 
a  danger  that  does  not  exist,  as  has  been  conclusively  proved 
by  postmortem  observations  of  Northrup,  Holt,  Rosenthal,  and 
others. 

External  applications  to  the  neck  are  often  indicated,  and, 
when  required,  are  grateful  to  the  patient  ;  of  these  the  cold 
pack,  or  ice  poultice,  stands  first.  Ice  can  be  applied  to  the  neck 
by  means  of  an  ice-bag  or  a  sausage  casing.  Sometimes  warmth 
is  more  agreeable. 

The  indications  for  the  operation  of  intubation  are,  in  the  main, 
the  same  as  those  for  tracheotomy.  The  most  pressing  indication 
is  the  appearance  of  recession  in  those  parts  of  the  chest  which 
yield  to  external  air  pressure,  with  continued  restlessness,  due  to 
insufficient  oxygenation  as  well  as  feebleness  of  respiration.  In 
cases  of  secondary  involvement  of  the  larynx,  where  the  patient 
is  more  exhausted  by  reason  of  the  coexisting  toxemia,  intuba- 
tion should  be  performed  at  once,  even  before  the  urgent  symp- 
toms of  stenosis  are  manifest. 

The  advantages  of  intubation  are  :  (i)  The  speed  with  which 
it  can  be  performed  ;  (2)  bloodlessness  ;  (3)  absence  of  shock 
following;  (4)  it  can  be  done  any  time,  day  or  night;  (5)  no 
need  of  anesthesia  or  other  preparations  ;  (6)  no  wound  is  made, 
•thus  the  spreading  of  infection  is  avoided ;  (7)  there  is  no  objec- 
tion on  the  part  of  the  parents  ;  (8)  the  inspired  air  enters  the 
lung  naturally  warmed  and  moistened ;  (9)  the  subsequent  care 
does  not  require  skilled  attendants. 

The   disadvantages  are:    (i)  It    clouds    the   prognosis;    (2) 


INTUBATION  OF  THE  LARYNX.  665 

induces  a  tendency  to  heart  failure  ;  (3)  its  dangers — (#)  pushing 
down  false  membranes  and  (<£)  suffocation  by  finger  or  attempts 
to  intubate  ;  (4)  difficulty  in  nourishing  patients. 

Prolonged  Use  of  the  Tube. — It  may  sometimes  happen 
that  on  the  removal  of  the  tube  the  case  may  not  have  fully 
recovered,  and  reintubation  be  necessary  ;  this  may  take  place  at 
once,  usually  within  the  first  twenty-four  hours,  and  in  some 
instances  not  until  a  week  has  elapsed.  When  the  reintubation 
is  necessary  at  once,  it  is  an  indication  that  the  exudate  is  still 
present,  and  the  patient  is  still  suffering  from  the  primary  dis- 
ease. But  when  intubation  is  required  after  a  number  of  days 
of  extubation  other  reasons  must  be  sought,  and  if  found,  rem- 
edied. By  the  prolonged  use  of  the  tube  is  meant  those  cases 
requiring  the  tube  after  the  specific  bacilli  have  disappeared,  or 
where  there  is  no  longer  any  appearance  of  the  membrane. 

A  tube  is  no  longer  necessary  if  the  child  can  breathe  without 
it,  and  three  weeks  should  be  the  longest  time  that  a  normal 
case  of  diphtheria  should  continue.  After  this  time  other  causes 
exist,  and  these  may  be  :  First  and  foremost,  paralysis  of  the 
vocal  cord  on  either  side ;  second,  edema  of  the  tissues  ;  third, 
ulceration  of  the  cricoid  cartilage,  with  consequent  collapse  ; 
fourth,  cicatricial  contractions  and  exuberent  granulations,  follow- 
ing ulcerations  and  paralysis  ;  fifth,  traumatism  and  its  results, 
injuries  inflicted  by  the  passage  of  the  tubes  in  or  out ;  sixth,  a 
too  tightly  fitting  tube ;  seventh,  leaving  the  tube  in  too  long. 

The  treatment  varies  with  the  case  :  The  first  indication  is 
collateral  treatment — the  large  dosage  of  strychnin,  with  food 
and  stimulants  ;  second,  the  use  of  gentle  local  medication  ;  third, 
the  frequent  extubation  of  the  tube,  with  intubation  of  one  slightly 
smaller.  In  cases  where  the  smaller  tube  is  used  care  must 
always  be  taken  that  the  physician  or  assistant  is  near  at  hand, 
for  the  patient  may  frequently  extubate  by  expectoration,  and 
death  has  been  noted  from  this  alone.  Fourth,  see  Tracheotomy. 

Removal  of  the  Tube. — Extubation  is  more  difficult  than 
the  act  of  intubation.  The  patient  and  assistants  are  arranged 
in  precisely  the  same  way  as  in  primary  operation.  The  index- 
finger  of  the  left  hand  acts  as  guide  for  the  extractor,  the  epi- 
glottis is  elevated,  the  point  of  the  extractor  enters  the  opening 
of  the  tube,  the  lever  is  pressed,  the  jaws  are  separated,  and  the 
tube  is  withdrawn  in  the  same  direction  as  it  was  inserted. 

When  to  Extubate. — The  advent  of  antitoxin  has  placed  the 
length  of  intubation  on  a  more  definite  basis.  It  is  safe  to  as- 
sume that  attempts  at  extubation  should  be  made  on  the  fourth 
or  fifth  day.  If  the  tube  is  withdrawn  and  stenosis  relieved  for 


666  THE   SPECIFIC    INFECTIOUS    DISEASES. 

from  four  to  six  hours,  it  is  safe  to  conclude  that  intubation  is  no 
longer  required.  We  should  always  be  prepared  to  perform  an 
immediate  secondary  intubation,  so  another  tube  should  be  pre- 
pared ready  at  hand  before  extubating.  It  is  well  to  have  the 
patient  abstain  from  food  for  a  few  hours  before  extubation,  and 
to  give  a  stimulant  immediately  before  the  operation.  After 
extubation  further  treatment  of  the  patient  will  be  required  for 
two  or  three  days,  or  until  convalescence  is  firmly  established. 

SCARLET  FEVER. 
Synonym. — SCARLATINA. 

Scarlet  fever  is  an  acute  specific  disease,  self-limited  and  very 
contagious,  characterized  by  sudden  onset,  vomiting,  sore  throat, 
and  oftentimes  convulsions,  and  accompanied  by  a  high  tempera- 
ture and  the  appearance  of  a  diffuse,  punctiform,  scarlet  rash, 
appearing  first  about  the  neck  and  shoulders.  One  attack  pro- 
tects from  others,  with  rare  exceptions.  It  occurs  in  epidemics, 
more  commonly  in  the  autumn  and  winter,  but  it  is  constantly 
endemic  in  populous  cities.  Some  unexplainable  reason  would 
seem  at  certain  times  to  favor  the  propagation  of 'scarlet  fever, 
causing  those  who  have  escaped  previously  to  yield  to  the  poi- 
son. The  usual  complications  are  membranous  inflammation  of 
the  pharynx,  frequently  extending  to  the  nose  and  ear  and  occa- 
sionally to  the  larynx.  The  sequelae  have  chiefly  to  do  with 
changes  in  the  kidney  and  middle  ear.  McCallom  says  that 
nephritis,  pneumonia,  pericarditis,  endocarditis,  dilatation  of  the 
heart,  otitis  media,  and  streptococcus-infection  must  be  consid- 
ered integral  parts  of  the  scarlatinal  process. 

Causes. — A  specific  micro-organism  has  long  been  suspected 
to  be  the  cause  of  scarlatina,  but  no  one  has  been  hitherto  gen- 
erally accepted  as  proved,  though  the  complications  exhibit  the 
effect  of  the  streptococcus  pyogenes  along  with,  oftentimes,  other 
pyogenic  germs.*  The  infection  enters  the  system  most  com- 

*  Dr.  Wm.  J.  Class,  of  Chicago,  has  only  recently  demonstrated  the  constant 
presence  of  a  micro-organism,  and  Dr.  Gradwohl  has  confirmed  his  observation.  We 
quote  from  a  letter  from  the  latter  to  us  while  the  work  is  in  press :  "In  answer  to 
your  question  as  to  the  probability  of  the  diplococcus  scarlatinae  (Class-Gradwohl) 
being  the  essential  cause  of  scarlet  fever,  I  will  make  this  statement :  when  we  take 
into  consideration  the  number  of  cases  of  scarlet  fever  in  which  this  micro-organism 
was  found,  by  both  Dr.  Class  and  myself,  in  the  blood,  in  the  throat,  in  the  scales, 
and  in  the  urine  of  these  patients ;  when  we  consider  that  it  produces  a  scaly 
eruption  in  swine  .and  also  an  acute  nephritis  in  guinea-pigs  and  swine  ;  that  it  kills 
mice  ;  that  it  can  be  recovered  from  these  animals  at  the  postmortem  examination — 
I  think  I  am  justified  in  calling  it  the  true  etiologic  agent  at  fault  in  the  production 
of  scarlet  fever." 


SCARLET    FEVER.  667 

monly  through  the  nose  or  throat.  It  is  by  some  regarded  as  a 
local  disease  of  the  throat,  followed  by  constitutional  symptoms. 
The  severity  of  the  angina  does  seem  to  be  an  index  of  the 
general  disturbance. 

Predisposition  plays  an  important  role,  individuals  varying 
widely  in  this  particular  and  the  same  persons  at  different  times. 
Certain  persons  constantly  exposed  escape,  and  long  afterward 
may  contract  the  disease.  Scarlatina  attacks  the  most  vigorous 
as  readily  as  those  of  feeble  constitution.  Age  is  a  potent  fac- 
tor in  the  propagation  and  mortality.  Babes  under  six  months 
rarely  contract  the  disease,  but  those  above  one  year  readily  do 
so,  and  among  them  the  mortality  is  high.  Incubation  is  from 
two  to  five  days,  more  or  less,  but  is  rarely  over  a  week.  A 
short  incubation  presumes  a  severe  case.  The  infection  is  not 
so  readily  transmitted  as  measles,  but  is  exceedingly  tenacious. 
Almost  any  object  coming  in  contact  with  the  sufferer  from 
scarlatina  may  retain  and  convey  it,  especially  those  which  have 
been  much  handled, — domestic  animals,  pets,  flowers,  books, 
clothing,  etc.,  are  convenient  vehicles, — and,  indeed,  almost  any 
object  may  be  the  medium  of  contagion.  The  morbific  principle 
remains  active  for  months  and  even  years.  No  age  nor  race  is 
exempt.  The  exact  origin  of  any  outbreak  is  hence  most  diffi- 
cult to  trace.  Milk  is  a  recognized  agent.  It  is  pointed  out  by 
H.  A.  Hall  that  scarlatina  occurs  in  epidemic  form  chiefly  in 
countries  or  places  where  cow's  milk  is  an  article  of  diet,  and  is 
absent  where  this  is  not  used.  The  secretions  of  the  patient  are 
the  most  dangerous  sources  of  infection,  in  particular  those  from 
the  mucous  membrane  and  from  the  skin,  and  especially  during 
the  stage  of  desquamation.  This  last  is  denied  by  some,  but  can 
not  be  practically  ignored.  During  incubation  the  patient  is 
scarcely  able  to  communicate  the  disease,  but  as  soon  as  the 
rash  appears  he  is  a  source  of  danger,  and  more  so  when  the 
disease  is  at  its  height  and  long  after,  indeed,  until  full  recovery, 
not  only  from  the  febrile  process,  but  from  the  protracted  des- 
quamation and  while  any  catarrhal  or  suppurative  output  con- 
tinues. The  feces  and  urine  are  to  be  feared,  especially  when 
there  is  nephritis  or  diarrhea  during  convalescence.  Quarantine 
should  be  maintained  until  the  child  is  completely  recovered  from 
the  disease  and  the  mucous  membranes  and  skin  show  no  trace 
of  disturbances. 

The  skin-lesion  consists  of  a  hyperemia,  with  dilatation  of 
superficial  vessels  and  infiltration  about  the  sweat-glands.  There 
are  destruction  of  the  lining  epithelium,  a  filling  of  the  lumen 
with  granular  detritus,  and  death  of  the  epiderm,  which  is  cast 
off  during  desquamation. 


668  THE    SPECIFIC    INFECTIOUS    DISEASES. 

Symptoms. — The  premonitory  symptoms  of  scarlatina  are 
sometimes  absent,  but  are  usually  severe,  and  consist  of  vomit- 
ing, chills,  fever,  convulsions,  angina,  etc.,  and  constitute  in  some 
sense  an  index  of  the  severity  of  the  attack  and  are  promptly 
followed  inside  of  a  day  or  a  day  and  a  half  by  the  rash.  In  a 
large  majority  of  cases  the  disease  arises  suddenly.  In  serious 
cases  the  fever  rises  abruptly  to  104°  to  105°  F.  (40°  to  40.5° 
C),  rarely  less  than  101°  F.  (38.3°  C.),  even  in  the  mildest. 
The  pharynx  will  early  exhibit  some  soreness,  but  there  may 
be  no  objective  appearances,  yet  usually  there  is  a  marked 
redness  over  the  fauces  and  tonsils,  consisting  of  a  uniform 
blush  or  a  series  of  small  punctate  spots  less  marked  than  in 
measles  ;  at  other  times  the  throat  resembles  follicular  tonsil- 
litis or  even  a  well-marked  attack  of  diphtheria.  These  throat 
symptoms  are  not  always  obvious  at  first ;  more  commonly  they 
show  a  little  later  in  the  disease, — two  or  three  days, — and  tend 
to  increase  in  severity  to  the  point  of  much  distress  and  greatly 
puzzle  the  physician.  Diphtheria  is  suspected,  but  bacteriologic 
study  seldom  reveals  the  Klebs-Loeffler  bacillus — more  com- 
monly the  streptococcus.  Well-marked  instances  of  the  mixed 
infection  are,  however,  recognized.  The  deep  cervical  glands  are 
usually  enlarged  or  soon  become  so. 

The  enlargement  of  the  superficial  lymphatic  glands  is  a 
marked  feature  of  scarlet  fever.  It  is  present  to  a  more  or 
less  marked  degree  in  many  of  the  infectious  diseases,  and  is 
especially  prominent  in  diphtheria,  rubeola,  and  scarlatina,  and 
may  be  merely  a  characteristic  phenomenon  of  these  disorders. 
Adenitis  is  more  commonly  found  among  children  than  in  adults. 
In  scarlet  fever  the  adenitis  occurs  from  the  first,  and  is  more 
marked  in  the  earlier  stages,  and  subsides  slowly  toward  the  end 
of  the  attack.  The  enlargement  of  the  glands  about  the  jaw 
and  neck  is  more  or  less  proportionate  to  the  intensity  of  the 
throat  involvement.  The  maxillary  glands  are  the  ones  which 
most  frequently  suppurate.  In  the  adenopathy  of  diphtheria 
there  is  a  wider  variation  and  a  greater  lack  of  uniformity  than 
in  that  of  scarlatina.  "  As  a  diagnostic  aid  in  differentiating  the 
rashes  of  diphtheria  from  scarlatina,  a  well-marked  enlargement 
of  all  the  superficial  glands,  especially  the  epitrochlear  and  axil- 
lary, would,  in  doubtful  cases,  I  think,  lead  one  to  throw  the 
balance  in  favor  of  scarlatina"  (Schamberg). 

In  scarlatina  all  the  lymphatic  structures  of  the  body  are 
hypertrophied,  and  there  is  a  hyperplasia  of  the  lymphoid  tissue 
of  the  spleen,  liver,  and  intestines.  Patients  with  high  tem- 
peratures and  well-marked  eruptions  are  apt  to  have  a  more 


THE 

*"  ^y^ 
SCARLET    FEVER.  669 

marked  adenopathy  than  those  with  but  little  fever  and  poorly 
marked  rashes. 

The  urine  is  generally  lessened  in  amount  and  of  higher 
specific  gravity,  deeper  color,  and  frequently  shows  traces  of 
albumin.  After  three  or  five  days  all  these  symptoms  subside, 
as  a  rule,  and  the  child  becomes  bright  and  active  once  more, 
unless  some  complication  impairs  its  vigor.  It  is  imperative  to 
keep  it  in  bed,  however,  as  exposure  to  chill  at  this  stage  is  ex- 
ceedingly perilous  and  liable  to  be  followed  by  serious  organic 
disturbance. 

The  tongue  of  scarlatina  has  been  described  as  typically  like  a 
strawberry,  that  of  measles  like  a  raspberry.  It  is  difficult  to 
find  such  simple,  graphic  pictures,  however,  nor  do  they  help 
materially  in  diagnosis.  A  most  important  and  characteristic 
symptom  of  scarlet  fever  is  the  enlargement  of  the  fungiform 
papillae  at  the  tip  and  edges  of  the  tongue.  This  may  be  slight 
and  overlooked,  but  it  is  constantly  present.  There  are  two 
varieties  of  this  :  in  one  the  papillae  have  the  appearance  of  small 
grains  of  Cayenne  pepper  sprinkled  on  the  tongue  ;  in  the  other 
the  papillae  protrude  like  little  buttons,  much  elevated,  but  not 
deeply  red.  The  "strawberry  tongue"  is  an  exaggeration  of 
this  condition.  This  symptom  appears  very  early  in  the  disease 
and  may  continue  for  twenty  or  thirty  days. 

After  the  first  evidence  of  disturbance  the  rash  may  appear  in 
half  a  day  to  a  day  and  a  half,  or  even  as  late  as  the  fifth,  usually 
beginning  about  the  neck  and  chest.  It  may  come  and  go  and 
at  first  escape  attention,  and  continue  from  three  days  to  a  week. 
In  an  epidemic  we  observed  and  reported,  occurring  in  the  Chil- 
dren's Hospital  in  1878,  of  eleven  cases,  in  none  the  rash  lasted 
over  a  week,  and  in  one  only  a  single  day.  The  color  is  dis- 
tinctly characteristic,  a  bright  scarlet,  resembling  Rotheln,  and 
not  the  crimson  of  measles,  which  is  more  purplish  in  tone. 
Color  alone  is  a  significant  guide  to  one  of  keen  color-sense,  but 
since  one  man  in  ten  is  bereft  of  this,  and  few  men  (though  all 
women)  possess  the  faculty,  this  depending  for  a  decision  upon 
comparisons  of  shades  and  tones  is  too  often  only  a  following  of 
precedent,  and  not  the  product  of  observation.  There  are  many 
irregularities  in  appearance  and  extent  of  the  erythema :  it  may 
be  absent  altogether,  or  appear  transiently  one  place  to-day, 
another  to-morrow,  or  may  cover  the  patient  from  head  to  heel. 

The  rash  of  scarlet  fever  is  a  punctate  erythema.  The  color 
is  difficult  of  word  depiction.  It  is  frequently  described  as 
of  a  bright  scarlet  or  boiled  lobster  tint.  By  actual  color 
comparison  at  the  bedside  such  a  characterization  is  seen 


6/O  THE    SPECIFIC    INFECTIOUS    DISEASES. 

to  be  inaccurate.  The  color,  to  be  sure,  varies  within  certain 
limitations  in  different  patients.  It  is  a  bright  or  dull  red,  usu- 
ally the  latter,  with  an  appreciable  element  of  brown  and  blue. 
Upon  close  inspection  the  rash  is  seen  to  be  made  up  of  small, 
deep-red  puncta,  surrounded  by  erythematous  areolae  of  a  some- 
what brighter  hue.  When  these  areolae  coalesce,  as  is  usually 
the  case,  a  diffuse  eruption  is  presented.  At  times,  however, 
there  is  some  intervening  normal  skin,  giving  the  eruption  a  more 
or  less  speckled  appearance.  This  is  not  infrequently  noted 
upon  the  flexor  surfaces  of  the  forearms,  in  which  region  the 
efflorescence  may  be  so  blotchy  as  to  excite  a  suspicion  of 
measles.  In  most  well-marked  eruptions,  and  occasionally  in 
mild  ones,  there  are  visible  numerous  pinpoint  to  pinhead-sized 
vesicles,  with  turbid  contents.  These  are  for  the  most  part  dis- 
tributed discretely  over  the  abdomen,  chest,  and,  to  a  lesser  ex- 
tent, upon  the  extremities.  At  times  they  are  closely  aggre- 
gated in  clusters,  and  may  even  coalesce,  with  the  production  of 
blebs.  In  rare  cases  the  vesicular  element  of  the  eruption  of  scarlet 
fever  may  be  so  marked  as  to  deceive  the  physician  as  to  the  true 
nature  of  the  rash.  Goose-flesh  papules  of  the  normal  skin  tint, 
located  at  the  site  of  the  hair  follicles,  may  be  present  in  large 
numbers  in  some  cases.  The  favorite  situation  is  the  lateral 
aspects  of  the  abdomen. 

The  rash  of  scarlet  fever  begins  upon  the  neck,  clavicular  region, 
and  chest,  spreading  thence  over  the  trunk  and  extremities. 
When  the  face  is  typically  involved,  a  characteristic  picture  is 
presented.  The  eruption  is  limited  to  the  forehead  and  cheeks, 
being  often  heightened  in  the  latter  region  by  a  dusky  red  or 
violaceous  flush  ;  the  upper  and  lower  lips  are  exempt,  their 
pallor  strongly  contrasting  with  the  surrounding  rash. 

The  rash  of  scarlet  fever  varies  greatly  in  intensity,  at  times 
being  so  slight  and  transitory  as  to  be  scarcely  recognized,  at 
other  times  being  so  intense  as  to  be  accompanied  by  swelling 
of  the  cutis  and  exaggeration  of  the  natural  furrows  of  the  skin, 
or  by  hemorrhage  into  its  structure. 

The  eruption  fades  in  from  two  to  eight  days,  and  is  followed 
by  desquamation.  This  usually  commences  upon  the  fifth  or 
sixth  day,  and  may  continue  for  six  or  seven  weeks.  Scaling 
begins  in  the  region  on  which  the  rash  has  first  appeared,  and  pre- 
serves the  sequence  of  the  progression  of  the  rash.  Upon  the 
trunk  it  is  first  seen  as  powdery  scaly  points  at  the  summits  of 
the  desiccated  miliary  vesicles.  These  increase  in  size  by  raising 
the  surrounding  horny  layer  until  a  small  "  collarette  "  or  jagged 
ring  of  desquamation  is  formed.  Neighboring  rings  soon  meet, 


SCARLET    FEVER.  6/1 

forming  patches  of  a  gyrate  or  geographic  outline.  Upon  the 
flexor  surfaces  of  the  hands  and  feet,  owing  to  the  thickness  of 
the  epidermis  in  these  regions,  the  skin  desquamates  in  lamellae 
or  strips  of  considerable  size,  and,  indeed,  in  rare  cases  may  be 
exfoliated  as  an  entire  epidermal  cast  of  the  member.  The 
amount  of  desquamation  is,  as  a  rule,  proportionate  to  the  inten- 
sity of  the  eruption.  In  very  mild  rashes,  therefore,  scaling  may 
only  be  visible  upon  close  scrutiny  of  the  skin. 

When  at  the  height,  too,  sometimes  the  rash  recedes, — "  strikes 
in," — producing  a  disturbance  in  the  minds  of  the  family  and 
friends.  This  is  rarely  a  cause  for  anxiety  ;  it  may,  however, 
indicate  lowered  vascular  tension,  weakened  heart  action,  and  is 
usually  restored,  both  the  rash  and  cardiac  action,  by  a  hot  bath 
or  pack.  Secondary  rashes  indicate  grave  conditions  and  deserve 
further  study.  The  rash  is  sometimes  nodular  or  papular,  caus- 
ing an  appearance  like  "  goose-flesh,"  or  vesicular.  It  may  come 
and  go  intermittently  ;  urticaria  may  coexist ;  occasionally  minute 
hemorrhages  appear  on  the  surface,  causing  an  appearance  of 
"  blackness  "  or,  rather,  a  deep  purple  ;  this  is  common  in  malig- 
nant cases,  but  is  not  constant.  Congestive  states  or  inflamma- 
tory disturbances  of  internal  organs  have  a  tendency  to  modify  the 
character  of  the  rash,  lessening  it,  as  a  rule. 

Itching  is  sometimes,  annoying,  but  not  so  intense  as  in 
measles.  As  the  rash  develops,  other  symptoms  increase  and 
then  lessen  with  its  subsidence.  As  the  rash  fades,  desquama- 
tion sets  in  ;  this  consists  of  an  exfoliation  of  dead  epithelium, 
and  the  form  is  characteristic.  If  the  surface  has  been  anointed 
by  soothing  applications  and  regularly  bathed,  this  is  far  less 
conspicuous  or  prolonged. 

It  is  a  common  experience  in  dispensaries,  and  occasionally  in 
private  practice,  to  meet  cases  of  the  various  complications — 
nephritis,  otitis,  and  the  like — in  whom  the  disease  has  not  been 
recognized  at  all  until  these  later  disorders  arise.  In  our  out- 
patient service  we  have  seen  many  such.  The  mere  appearance 
of  this  peculiar  form  of  desquamation  is  practical  proof  of  pre- 
existent  scarlatina.  Cases  vary  from  the  mildest,  wherein  the 
temperature  is  not  above  101°  F.  to  102°  F.  (38.3°  to  38.8°  C.), 
a  fugitive  rash,  slight  pharyngitis,  all  subsiding  in  three  or  four 
days,  to  those  of  moderate  seventy,  sharp  prodromes,  and 
well-marked  symptoms,  temperature  105°  F.  (40.5°  C.),  "boiled 
lobster"  rash,  longer  duration  five  to  seven  days;  and,  finally, 
malignant  cases,  with  short  incubation,  intense  initial  symp- 
toms, early  and  full  exanthem,  higher  and  longer  fever,  severe 
and  varied  complications,  intense  angina,  congestion  and  ulcera- 


6/2  THE    SPECIFIC    INFECTIOUS    DISEASES. 

tion,  sores  on  lips  and  teeth,  cervical  lymphadenitis  with  brawny 
cellulitis,  fetid  nasopharyngeal  catarrh,  and  general  septic  symp- 
toms. In  these  cases  the  temperature  leaps  up  and  remains  high 
for  a  week  or  ten  days.*  We  had  a  notable  case,  a  boy  of 
twelve,  presenting  all  these  phenomena,  until  the  dyspnea  and 
heart  failure  compelled  us  to  abandon  hope ;  the  urine  was 
loaded  with  albumin  and  growing  scanty.  Suddenly  the  urine 
became  loaded  also  with  uric  acid  crystals  (which  was  beyond 
all  previous  or  later  experience  in  acid  urines),  and  continued 
thus  for  two  days,  during  and  after  which  all  the  danger-signals 
were  lowered  and  the  boy  made  a  perfect  recovery,  and  to-day, 
fifteen  years  later,  is  apparently  in  perfect  health. 

In  severe  epidemics  there  are  met  with  rare  instances  of  sud- 
den overwhelming  severity,  "fulminating,"  or  lightning  cases,  in 
whom  death  takes  place  before  the  recognizable  symptoms  de- 
clare themselves.  There  are  usually  evidences  of  cerebral  distur- 
bance,— vomiting,  convulsions,  headache,  and  the  like, — followed 
quickly  by  evidences  of  organic  failure  and  it  may  be  of  hyper- 
pyrexia  (107°  F. — 41.6°  C). 

The  heart  should  be  carefully  examined.  Sometimes  endo- 
cardial  murmurs  are  heard,  disappearing  entirely.  Endocarditis 
or  pericarditis  occasionally  arises  alone,  or  in  connection  with 
other  complications.  The  lungs  are  not  often  affected,  but  bron- 
chitis, bronchopneumonia,  or  pneumonia  is  present  at  times. 

Surgical  scarlatina  is  a  curious  condition  not  well  understood, 
wherein  after  slight  or  other  operation  scarlatina  becomes  inocu- 
lated. This  is  usually  from  accidental  exposure  in  one  not  pro- 
tected by  a  previous  attack.  The  operation  seems  to  render  the 
subject  peculiarly  susceptible.  This  form  of  scarlatina  is  gener- 
ally atypic  :  short  incubation,  noncharacteristic  rash,  irregular 
but  severe  nervous  phenomena,  are  common.  Some  observers 
deny  that  these  manifestations  are  aught  else  than  peculiar  forms 

*  McCallom  distinguishes  five  types  of  scarlatina:  (i)  Temperature,  very  small 
rise,  perhaps  one  degree  ;  no  eruption  on  the  body  or  only  a  transient  erythema,  but 
seen  slightly  in  the  throat,  which  is  congested  ;  some  dysphagia,  hands  dry  and  hard. 
The  diagnosis  is  based  on  the  enlargement  of  the  papillae  at  the  tip  and  edge  of  the 
tongue,  a  constant  feature  in  all  his  1000  cases.  From  these  mild  cases,  often  un- 
recognized, much  infection  is  derived,  and  among  them  organic  disease  often  arises. 

(2)  An  eruption,  characteristic  but  brilliant,  more  marked  in  the  axillae  and  inguinal 
regions ;  subjective  throat  symptoms  not  prominent ;  temperature  from  99°  to  100°  F. 

(3)  High  temperature  for  three  or  four  days,  and  brilliant  rash  ;  throat  symptoms  well 
marked  but  not  conspicuous ;  no  nasal  discharge.     (4)  Moderately  high  temperature — 
102°  to  103°  F.  ;  marked  throat  symptoms  and  profuse  nasal  discharge,  in  which 
streptococci  are  found ;  enlargement  of  the  cervical  glands  occasionally  observed. 
The  temperature  remained  elevated  for  from  ten  to  fourteen  days,  and  came  down  by 
lysis.     The  patients  were  mildly  delirious  or  in  a  semiconscious  state,  the  eruption  in 
most  cases  brilliant,  but  in  some  instances  extremely  pale. 


SCARLET    FEVER.  673 

of  septicemia,  but  it  is  demonstrated  that  from  them  scarlatina  is 
often  spread,  and  that  the  sequelae  common  to  this  disease  follow, 
such  as  nephritis  and  otitis. 

The  urine  in  scarlatina  is  generally  lessened  in  amount,  of 
higher  specific  gravity  and  of  a  deeper  color,  frequently  show- 
ing traces  of  albumin.*  As  a  rule,  all  these  symptoms  subside 
after  three  to  five  days,  and  the  child  becomes  bright  and  active 
once  more,  unless  some  complication  impairs  its  vigor.  It  is 
imperative  to  keep  the  child  yet  a  while  in  bed,  as  exposure 
now  is  exceedingly  perilous,  and  it  is  at  just  such  times  that 
future  disastrous  happenings  are  begun. 

The  kidneys  are,  next  to  the  throat,  most  commonly  affected 
— in  the  milder  cases  only  temporarily,  by  the  appearance  of 
febrile  albuminuria,  which  is,  according  to  Delafield,  an  acute 
degeneration  of  the  kidneys,  direct  irritation  of  the  epithelium 
of  the  tubules  by  the  toxin  eliminated  by  the  kidneys.  The 
microscope  shows  a  granular  degeneration  and  death  of  the 
epithelium  of  the  tubules.  It  is  the  appearance  known  as 
"  cloudy  swelling."  This  condition  entirely  clears  up  upon  the 
recovery  of  the  patient,  and  calls  for  no  further  treatment  than  a 
continuance  of  fluid  diet.  Pronounced  lessening  of  the  amount 
of  urine  is  of  grave  import. 

Bauer  and  Deutsch,  studying  the  condition  of  the  stomach  in 
the  infectious  fevers,  found  in  scarlatina  that  the  free  hydrochloric 
acid  is  usually  absent  until  after  the  temperature  had  fallen  to 
normal  for  six  or  seven  days,  though  in  some  cases  it  was  present 
at  the  beginning  of  the  fever,  absorption  being  augmented  some- 
what, the  mobility  remaining  normal. 

Slight  transient  paralyses  have  been  noted  (Meyer,  Alexieff). 

Diagnosis. — It  is  often  exceedingly  difficult  to  be  absolutely 
certain  of  the  diagnosis  of  scarlatina  in  less  than  two  or  three 
days  or  until  the  later  phenomena  appear.  Notwithstanding  the 
clear  picture  ordinarily  exhibited  of  the  short  incubation,  vomit- 
ing of  onset,  sudden  and  marked  rise  of  temperature  to  100.5° 
or  103°  F.,  early  appearance  of  erythema  and  angina,  pronounced 
constitutional  symptoms  and  early  appearance  of  albuminuria, 
etc.,  nevertheless  there  are  other  conditions  which  present  most 
of  these  features  at  times.  The  enlargement  of  the  papillae 


*  According  to  McCallom,  39  per  cent,  of  cases  showed  the  slightest  possible 
trace  of  albumin  in  1000  cases,  a  very  slight  trace  in  4.5  per  cent.,  a  slight  trace  in 
9.3  per  cent.,  a  trace  in  6.8  per  cent.,  a  large  trace  in  2.7  per  cent.  In  five  cases  the 
albumin  was  one-half  of  one  per  cent.,  and  three  of  these  died.  A  few  patients 
who  recovered  had  complete  suppression  of  urine  for  a  short  time.  In  only  three 
cases  was  the  acute  renal  trouble  followed  by  chronic  disease. 
43 


6/4  THE    SPECIFIC    INFECTIOUS    DISEASES. 

at  the  tip  and  edges  of  the  tongue  is  said  by  McCallom  to  be  suffi- 
cient to  base  a  diagnosis  on  in  the  absence  of  erythema  or  rash. 
The  chief  difficulties  lie  in  the  irregularities  in  the  distribution 
and  character  of  the  eruption,  whereas  a  typical  scarlatiniform 
rash  is  occasionally  due  to  other  diseases, — influenza,  Rotheln, 
diphtheria, — and  also  to  the  ingestion  of  certain  drugs.  The 
diagnosis  of  a  typical  scarlatinal  rash  presents  few  difficulties,  but 
the  atypical  forms  are  most  perplexing.  Certain  forms  of  anti- 
toxin rash  are  markedly  like  scarlatina.  Subjective  throat  symp- 
toms are  frequent,  but  not  constant  enough  on  which  to  base  an 
opinion.  Objective  throat  symptoms  are  always  to  be  discov- 
ered, and  are  a  great  aid  in  diagnosis.  "  The  appearance  of  a 
punctate  eruption  in  the  axillae  and  groins,  with  congestion  of 
the  tonsils  and  a  punctate  eruption  on  the  roof  of  the  mouth, 
no  matter  whether  there  is  any  eruption  anywhere  else  or  not, 
are  positive  proofs  of  scarlet  fever"  (McCallom). 

To  make  a  diagnosis  after  the  eruption  has  faded  or  changed 
is  often  most  important.  A  white  line  at  the  junction  of  the  pulp 
of  the  finger  with  the  nail,  showing  the  commencement  of  des- 
quamation,  is  of  great  significance. 

Complications. — The  most  prominent  complications  of  scar- 
latina are  observed  in  the  throat.  There  is  almost  always  present, 
as  a  constant  factor,  an  erythematous  blush,  somewhat  punctate, 
spread  over  the  mucous  membrane,  hard  palate,  and  upon  the 
tonsils,  which  are  swollen,  and  small,  membranous-looking  exu- 
dates  are  seen  on  them,  which  are  easily  wiped  off.  When  this 
symptom  is  severe,  the  appearances  closely  resemble  diphtheria  : 
so  much  so  that  many  yet  regard  this  state  as  a  combination  of 
the  two  diseases,  but  it  is  proved  by  bacteriologic  studies  to  be 
due  to  the  streptococcus,  and  only  very  rarely  to  the  Klebs- 
Loeffler  bacillus  (pseudodiphtheria).  Late  in  the  disease,  after 
the  subsidence  of  the  primary  fever,  true  diphtheria  may  also 
coexist.  The  scarlet  fever  patient  is  particularly  susceptible  to 
diphtheria,  but  the  diphtheria  patient  is  not  susceptible  to  scar- 
latina. 

Should  this  membranous  condition,  from  whatsoever  cause, 
become  severe,  the  local  dangers  are  from  extension  along  the 
mucous  membrane  of  the  nasopharynx  and  Eustachian  tube  to 
the  middle  ear.  Swallowing  is  made  difficult  and  painful ;  the 
breath  is  fetid ;  irritating  discharges  exude  from  the  nose  and 
throat ;  respiration  is  impeded,  and  the  larynx  is  so  narrowed  by 
obstructing  membranes  as  to  imperil  life  directly.  Along  with 
this  the  glands  of  the  neck  are  invaded,  a  dense  cellulitis  is  set 
up,  often  extending  from  ear  to  ear.  Constitutional  symptoms 


SCARLET    FEVER.  675 

are  severe,  too,  owing  to  streptococcus  toxemia  or  to  suppuration 
in  the  glands,  pneumonia,  or  nephritis.  In  the  very  worst  cases 
gangrene  may  set  in,  causing  extensive  loss  of  tissue,  or,  along 
with  a  profound  increase  of  the  aforesaid  symptoms,  the  mem- 
branes become  darker  and  dirtier  looking,  sloughing  takes  place, 
often  extensive,  involving  the  blood-vessels,  and  fatal  hemor- 
rhage may  result. 

The  accompanying  constitutional  features  are  shown  by  incre- 
ments of  intensity  of  all  bad  symptoms,  profound  asthenia  and 
cachexia,  with  little  or  no  tendency  to  repair. 

The  cervical  lymph-nodes  are  swollen  in  almost  all  cases, 
especially  when  accompanied  by  severe  throat  trouble,  which 
may  remain  as  merely  an  acute  inflammation  or  proceed  to  sup- 
puration. A  cellulitis  of  the  neck  may  accompany,  especially 
toward  the  end  of  the  first  week.  This  should  be  relieved  early 
by  free  incision,  or  it  may  extend  to  the  deep  tissues  and 
involve  the  blood-vessels,  hence  producing  hemorrhages.  A 
marked  leukocytosis  is  usually  found  when  suppuration  sets  in. 

The  ears,  so  commonly  involved  in  scarlatina,  are  affected  by 
extension  along  the  Eustachian  tube  from  inflammation  in  the 
throat.  It  occurs  in  younger  children,  and  varies  with  the  char- 
acter of  the  epidemic,  yet  in  some  severe  ones  the  feature  is  often 
rare.  Otitis  arises  at  the  height  of  the  disease  or  during  con- 
valescence. There  may  then  be  pain,  high  fever,  and  recogniz- 
able deafness,  or  otitis  may  be  accompanied  by  no  special  sub- 
jective symptom,  and  only  give  evidence  by  pyemic  states  or 
meningitis.  The  exceptional  rise  in  fever  which  usually  accom- 
panies this  falls  promptly  when  the  drum  ruptures. 

The  treatment  of  painful  conditions  of  the  ear  is  heat,  preferably 
dry,  as  from  a  hot-water  bag,  hot  salt,  bran,  brick,  or  soapstone, 
the  child's  head  to  be  laid  on  this,  a  thin  pillow  intervening. 
Prolonged  poulticing  encourages  suppuration,  hence  should  not 
be  practised.  A  small  object,  like  a  glove-finger,  filled  with  hot 
salt  and  gently  placed  in  the  ear,  gives  comfort.  One  should 
never  drop  oil  or  laudanum  in  the  ear  of  a  child.  Blood-letting 
by  leeches  is  valuable  in  those  not  too  young  or  too  weak.  After 
these  means  are  used,  opium  may  be  tried  cautiously  for  the 
relief  of  pain.  Should  the  pain  continue  or  increase  and  the 
temperature  remain  high,  or  if  cerebral  symptoms  are  added, 
operation  is  called  for.  It  is  not  a  difficult  thing  to  make  a 
puncture  into  the  ear-drum,  and  should  be  done  when  indicated. 
This  will  relieve  tension  and  pain  and  let  out  a  little  blood  ;  thus 
the  formation  of  pus  is  possibly  prevented  and  much  suffering 
avoided.  Later,  operation  may  be  demanded  to  let  out  pus  and 


676  THE    SPECIFIC    INFECTIOUS    DISEASES. 

to  prevent  extension  of  inflammation  to  the  bony  parts,  but  this 
is  better  done  by  a  skilled  aurist.  When  the  drum  is  incised  or 
ruptured,  the  discharge  should  be  carefully  and  persistently 
cleaned  away.  This  is  best  done  by  a  soft-rubber  ear  syringe 
and  a  warm  lotion  (85°  or  90°  F.)  of  saturated  solution  of  boric 
acid,  normal  salt  solution,  or  bichlorid,  I  :  5000,  and,  if  abundant, 
repeated  every  two  or  three  hours,  or  at  least  several  times  a  day. 
Use  no  cotton  covering  nor  plugging.  To  dislodge  accumula- 
tions of  pus  peroxid  of  hydrogen  is  useful,  alone  or  diluted. 
(See  chapter  on  Diseases  of  the  Ear.)  The  nose  should  be 
cleansed,  too,  regularly,  by  atomizer  in  an  older  child  or  drop- 
ping-tube  in  infants,  using  Dobell's  or  Seller's  or  other  alkaline 
antiseptic  solution,  warmed. 

The  nervous  system  is  rarely  affected  in  scarlatina  further  than 
is  shown  by  the  convulsions  and  vomiting  of  onset.  Meningitis 
may  follow  severe  otitis,  by  extension.  The  digestive  organs 
are  disturbed,  as  in  other  febrile  processes.  The  vomiting  of 
onset  is  rather  an  evidence  of  systemic  poisoning  than  a  local 
disorder,  or  it  may  point  to  cerebral  computations.  Its  occur- 
rence late  in  the  disease  may  evidence  uremia.  The  tongue 
exhibits  a  peculiar  coating,  which  clears  off  in  a  characteristic 
manner,  giving  rise  to  the  so-called  strawberry  appearance.  In 
typical  cases  there  is  usually  a  rapid  rise  in  temperature,  103°  to 
105°  F.  (39.4°  to  40.5°  C),  even  in  the  mildest  above  100°  F. 
(37-7°  C.),  and  along  with  this  is  an  increase  in  force  and  fre- 
quency of  the  pulse  (from  120  to  150  beats)  in  excess  of  what 
the  state  of  the  child  would  apparently  warrant.  Among  the 
other  complications  which  are  occasionally  met  with  in  scarla- 
tina may  be  mentioned  hyperpyrexia,  endocarditis,  pericarditis, 
pneumonia,  suppuration  of  the  lymphatic  glands,  ophthalmia,  and 
a  peculiar  form  of  arthritis  which  closely  resembles  rheumatism. 

The  influence  of  the  scarlatinal  poison  on  the  heart  is  a  very 
marked  one.  Mitral  systolic  murmurs  are  most  common  ;  a 
"  bruit  de  galop  "  is  occasionally  heard  ;  irregularity  of  the  heart 
action  is  not  uncommon.  Endocarditis  and  pericarditis  are 
occasionally  met.  The  area  of  dullness  is  often  increased  ;  rapid 
dilatation  also  sometimes  occurs.  Transitory  murmurs  are  often 
heard.  The  heart  muscle  loses  its  tone,  and  is  unable  to  con- 
tract sufficiently  to  close  the  valves  tightly,  and  from  this  condi- 
tion the  murmur  may  come. 

Second  attacks  of  scarlatina  are  not  very  rare.  Relapses 
occur  somewhat  rarely,  and  must  be  distinguished  from  rein- 
fections. A  true  relapse  shows  itself  in  from  thirty-five  to  forty 
days  after  the  disappearance  of  the  exanthem  (McCallom),  and 


SCARLET    FEVER.  677 

would  be  ushered  in  by  the  usual  symptoms  of  the  disease.  A 
pseudo-relapse  or  reversio  eruptionis  takes  place  just  after  the 
disappearance  of  the  exanthem.  A  reinfection  may  take  place  in 
about  fifty  days  after  the  eruption  has  faded,  and  is  not  accom- 
panied by  very  violent  symptoms,  as  a  rule,  though  death  may 
result. 

Prognosis. — The  prognosis  in  scarlet  fever  is  favorable  when 
cases  are  carefully  isolated  and  judiciously  treated  from  the  start. 
The  severity  of  the  infection  varies  widely  in  different  epidemics, 
and  in  different  years  under  somewhat  similar  circumstances, 
from  a  fraction  of  i  per  cent,  to  25  per  cent,  or  more.  In  all 
mild  cases,  especially  with  marked  albuminuria,  the  prognosis 
should  be  guarded.  The  kidneys  may  suddenly  cease  to  act, 
whereas  they  had  showed  previously  no  evidences  of  deficient 
or  disordered  function.  Profuse  diarrhea  is  always  a  grave 
symptom.  The  hemorrhagic  form  is  very  serious.  Strepto- 
coccus-infection plays  an  important  role  in  the  fatal  result. 

Treatment. — The  preventive  treatment  of  scarlet  fever  is  by 
far  the  most  important,  and  is  more  practicable  than  in  any 
other  exanthem,  because  the  infectious  principle,  although  most 
tenacious  of  life,  is  not  so  active  as  that  of  some  other  diseases. 
Strict  quarantine  is  particularly  efficacious,  and  thorough  cleans- 
ing and  exposure  to  sunlight  and  air  day  and  night  will  usually 
destroy  the  focus  of  disease.  Isolation,  with  proper  precautions, 
is  entirely  effective  in  this  disorder.  A  room  should  be  chosen 
which  can  be  isolated ;  if  this  is  impossible,  keep  the  child  in 
the  same  one  in  which  the  infection  first  showed  itself,  and  do 
the  best  practicable.  The  care  of  the  room  is  of  the  first  import- 
ance :  every  movable  object  should  be  taken  out  except  those 
absolutely  needed.  Temporary  curtains  of  sheets  wrung  out  of 
antiseptic  solutions  (Labarraque's  or  bichlorid)  may  be  hung  in 
front  of  doors.  The  dresses  of  the  attendants  should  be  wash- 
able, and  their  hair  protected  from  contamination  by  a  close- 
fitting  cap.  The  physician  should  never  enter  the  sick-room 
without  extreme  precautions,  and  should  be  specially  attired. 
The  room  should  be  exposed  to  the  sun  and  kept  cool  and  airy, 
provided  with,  if  possible,  an  open  fireplace,  the  temperature,  at 
first,  68°  F.  at  the  head  of  the  bed  ;  later,  cooler  if  fever  is  high, 
or  warmer  if  complications  arise.  The  body  of  the  patient  is  the 
better  for  constant  anointing  with  boric  ointment,  which  should 
be  wiped  off  afterward  and  will  thus  assist  in  cleansing  as  well 
as  disinfecting,  and  prevent  the  spread  of  the  epithelial  scales 
during  the  process  of  desquamation,  which  are  so  highly  infec- 
tious. This  should  be  supplemented  by  daily  spongings  of  the 


6/8  THE    SPECIFIC    INFECTIOUS    DISEASES. 

surface  in  tepid  water,  to  which  it  is  well  to  add  green  soap. 
Recent  observers  report  excellent  results  from  rubbing  the  body 
three  or  four  times  a  day  with  oil  of  eucalyptus  or  5  per  cent, 
ichthyol.  (For  further  remarks  on  disinfection  of  the  room  and 
clothing  see  Diphtheria.) 

In  the  prophylaxis  of  the  individual  it  is  especially  important 
that  the  throat  receive  attention,  not  only  of  the  patient,  but  of 
all  others  exposed  to  the  infection.  In  the  patient  it  seems 
probable  that  an  ill-conditioned  nasopharynx  is  the  instrumental 
cause  of  additional  infection,  hence  complications.  This  should 
receive  almost  the  first  and  constant  attention,  by  means  of  anti- 
septic washes  and  applications,  astringent  and  other. 

Scarlatina  is  a  self-limited  disease,  and  no  remedy  controls  or 
arrests.  The  bowels  require  the  first  medication,  and  it  is  par- 
ticularly wise,  as  Jacobi  urges,  to  use,  in  the  very  beginning  of 
the  disease,  moderately  laxative  doses  of  calomel,  and  to  repeat 
the  use  of  calomel  on  the  first  appearance  of  nephritis.  The  diet 
should  be  carefully  limited  to  milk  and  milk  preparations,  light 
soups,  and  broths,  although  there  may  be  permitted,  as  soon  as 
the  fever  subsides  below  102°  F.  (38.8°  C.),  moderate  amounts 
of  starchy  and  other  foods.  The  general  treatment  of  scarlet 
fever  is  an  intelligent  expectancy,  watching  the  symptoms  with 
a  critical  eye.  The  system  is  laboring  under  an  intense  poison, 
which  can  not  be  artificially  eliminated.  If  the  rash  does  not 
come  out  adequately  on  the  skin,  warm  or  hot  baths  to  the 
entire  surface  or  only  the  feet  should  be  employed,  or,  possibly, 
the  wet -pack  or  mustard  bath,  with  the  internal  use  of  hot  drinks 
or  febrifuges,  such  as  the  solution  of  ammonium  acetate,  alone 
or  with  citrate  of  potassium.  For  high  arterial  tension  aconite 
is  the  safest  remedy,  repeated  in  drop  doses  every  quarter  or 
half-hour,  and  then  at  lengthening  intervals,  along  with  the 
saline  diuretics  mentioned  previously.  If  cerebral  symptoms 
appear,  it  is  well  to  give  several  doses  of  calomel  and  a  mixture 
of  bromid  of  sodium  with  chloral  hydrate,  or  even  Dover's  pow- 
der or  other  opiate,  especially  codein.  If  this  is  during  hyper- 
pyrexia,  coal-tar  antipyretics  and  brandy  work  happily,  provided 
cold  applications  are  insufficient.  Disturbances  of  the  digestion 
are  not  particularly  common  :  vomiting  is  occasionally  trouble- 
some at  first,  for  which  bismuth  preparations  along  with  small 
doses  of  calomel  are  useful,  given  dry  on  the  tongue,  or,  for 
younger  children,  bismuth  in  solution,  along  with  the  aromatic 
waters,  as  the  equal  parts  of  chloroform-,  cinnamon-,  and  lime- 
water.  Diarrhea  may  be  controlled  by  very  much  the  same 
measures,  to  which  may  be  added  a  little  paregoric,  Dover's 


SCARLET    FEVER.  6/9 

powder,  or  carbolic  acid  in  minutt  doses.  The  cervical  adenitis, 
so  distressing  in  appearance,  is  to  be  best  controlled  by  local 
cleansing  of  the  nose  and  nasopharynx,  and  by  applications  of 
cold  or  lead-water  and  laudanum,  rather  than  by  the  time- 
honored  officious  medication,  by  iodin,  mustard,  etc.,  externally 
applied. 

Rheumatism,  or  that  arthritis  which  very  closely  resembles  it, 
is  a  frequent  and  early  complication,  appearing  often  within  the 
first  week,  and  is  controllable  by  the  salicylates,  combined,  if  very 
painful,  with  small  doses  of  acetanilid,  phenacetin,  or  the  other 
coal-tar  analgesics.  The  affected  joints  should  be  wrapped  in 
cotton- wool,  with  moist  applications  of  some  alkali  or  methyl 
salicylate.  This  may  be  complicated  by  endocarditis  or  pericar- 
ditis, which  demands  extra  precaution  and  appropriate  treatment. 
(See  Endocarditis.)  The  lungs  are  not  so  frequently  affected  as 
in  measles  ;  nevertheless  they  occasionally  suffer.  The  heart,  as 
in  all  infectious  processes,  demands  the  most  solicitous  watch- 
ing. The  most  serious  complication  of  scarlet  fever  is  nephritis. 
This  varies  according  to  different  epidemics,  and  also  with  the 
amount  of  care  the  patient  gets  from  the  first.  Probably  the 
worst  cases  arise  from  mild  attacks  of  the  fever,  which  frequently 
escape  detection,  and  hence  for  which  insufficient  precautions  are 
used.  Rest  in  bed  is  absolutely  essential  to  safety,  as  only  thus 
can  a  uniform  temperature  be  maintained  over  the  entire  skin  sur- 
face. The  urine  should  be  examined  almost  daily  from  the  first, 
and  also  long  after  the  child  has  been  allowed  to  get  up  and  be 
about.  Should  albumin  appear,  the  urine  become  scanty,  or  the 
limbs  dropsical,  every  effort  should  be  directed  to  encouraging 
the  action  of  the  skin  and  intestines,  which  must  then  assume 
part  of  the  functions  of  the  damaged  kidney.  Water  is  the  great 
diuretic,  especially  a  bland  water  free  from  salines,  and  the  child 
must  be  induced  by  various  devices  to  consume  as  much  of  this 
as  possible.  All  sorts  of  innocent  things  may  be  added  to 
water  for  this  purpose,  making  it  as  attractive  as  possible.  The 
skin  must  be  excited  by  baths,  warm  and  gradually  heated  from 
95°  F.  (35°  C.)  up  to  100°  or  105°  F.  (37.7°  to  40.5°  C.) ;  or 
by  the  wet-pack,  and,  again  changing  these,  if  depression  sets 
in,  to  hot-air  baths  and  foot-baths.  Ichthyol,  5  per  cent,  in 
lanolin,  is  extolled  as  an  antiseptic  application.  Of  medicines, 
pilocarpin  stands  at  the  head,  from  -^  to  -^  of  a  grain,  also  the 
acetate  and  citrate  of  potassium,  made  agreeable  by  lemon-juice 
or  other  aromatics.  Cathartics  are  often  required,  such  as  calo- 
mel or  the  compound  jalap  powder,  but  may  become  dangerous, 
depleting  the  blood  and  weakening  the  heart.  Locally,  poul- 


68O  THE    SPECIFIC    INFECTIOUS    DISEASES. 

tices  do  service.  Dry  cupping  has  its  merits,  too  ;  also  stimulat- 
ing liniments  and  local  wet-packs.  Later,  if  anemia  is  apparent, 
a  well-matured  tincture  of  the  chlorid  of  iron  is  an  efficient 
remedy,  alone  or  added  to  dilute  phosphoric  acid  or  in  the  form 
of  Basham's  mixture.  If  blood  appears  in  the  urine,  astringents 
are  required  :  ergot  and  gallic  acid  and  nitroglycerin,  -g^-g-  to  -^-^ 
of  a  grain  in  alcoholic  solution. 

Cerebral  complications,  restlessness,  continued  convulsions, 
insomnia,  and  delirium  are  in  a  great  measure  the  result  of  the 
intensity  of  the  febrile  movement,  and  in  a  sense  are  the  criteria 
of  the  severity  of  the  disease.  These  are  best  controlled  by  the 
water  applications, — baths,  packs,  etc., — and  if  continued,  by  cold 
to  the  head — a  good  way  is  to  hold  the  child's  head  over  the 
side  of  the  bed  and  pour  cold  water  on  it.  Convulsions  may  be 
evidences  of  uremia. 

Malignant  cases  demand  powerful  stimulation  with  ammonia, 
whisky,  caffein,  and  musk,  along  with  strychnin.  Alcohol  may 
act  as  a  useful  tranquilizing  agent. 

The  throat  is  constantly  an  object  of  solicitude.  In  almost  all 
cases  is  seen  the  characteristic  macular  eruption  on  the  pillars  of 
the  pharynx,  posterior  walls,  and  uvula.  Here  antiseptic  and 
astringent  solutions  are  of  value  to  relieve  symptoms. 

M.  Roger,  Huber,  and  Blumenthal  have  recently  reported  good 
results  from  the  injection  of  serum  from  convalescents.  Gordon 
reports  good  results  from  antistreptococcic  serum  ;  Rappapart 
regards  it  as  useless. 

VARIOLA. 
Synonym. — SMALLPOX. 

Variola  is  an  acute  infectious  disease,  characterized  by  a  sud- 
den onset,  severe  frontal  headaches,  lumbar  pains,  and  abrupt 
fever,  which  falls  to  normal  or  nearly  so  upon  the  appearance  of 
an  eruption,  which  passes  through  the  stages  of  papule,  vesicle, 
pustule,  and  crust.  It  is  now  seldom  seen  in  civilized  countries, 
being  entirely  under  the  control  of  vaccination. 

Causes. — Smallpox  is  one  of  the  most  virulent  of  the  con- 
tagious diseases,  and  it  is  in  all  probability  due  to  a  micro- 
organism, although  the  specific  cause  or  germ  has  not,  as  yet, 
been  isolated.  The  contagium  is  contained  in  the  secretions  and 
excretions,  the  exhaled  air,  and  the  pustules,  and  may  remain 
dormant  for  a  long  time  in  clothing  or  other  objects. 

Unless  protected  by  vaccination  or  a  previous  attack  of  small- 
pox, most  people  are  susceptible.  All  ages  are  attacked,  from  the 


VARIOLA.  68 1 

very  old  to  the  fetus  in  utero.  Sex  has  no  influence.  It  is 
claimed  by  some  that  the  colored  race  is  more  susceptible  than 
the  white. 

Symptoms. — Smallpox  is  usually  divided,  according  to  the 
severity  of  the  process,  into  three  classes,  as  follows  :  (i)  Variola 
vera  (discrete  and  confluent),  true  smallpox  ;  (2)  variola  haemor- 
rhagica,  or  black  smallpox  ;  (3)  varioloid  or  modified  smallpox. 

The  incubation  period  of  smallpox  ranges  from  ten  to  eighteen 
days,  but  by  far  the  most  usual  time  is  fourteen  days. 

The  stage  of  invasion  usually  begins  in  children  with  a 
convulsion,  followed  by  a  sudden  rise  in  temperature,  frontal 
headache,  and  distressing  lumbar  pains.  Vomiting  is  often  an 
annoying  symptom.  The  fever  rises  rapidly,  and  reaches  its 
height  at  about  the  end  of  forty-eight  hours,  and  ranges  from 
103°  to  105°  F.  (39.4°  to  40.5°  C).  With  the  high  fever  there 
are  often  associated  marked  delirium  and  restlessness. 

The  pulse  is  rapid  and  full,  but  not  dicrotic.  Vomiting  or 
anorexia  is  the  rule  ;  also  constipation  at  the  beginning. 

During  this  stage  the  preemptive  rashes  are  seen.  They 
are  either  fine,  resembling  scarlatina,  or  macular,  resembling 
measles.  Petechiae  are  also  noticed,  as  well  as  urticaria.  These 
rashes  occur  in  from  10  to  16  per  cent,  of  all  cases. 

Eruption. — (/)  The  Discrete  Form. — The  eruption  begins  to 
appear  at  the  end  of  the  third  or  the  beginning  of  the  fourth  day, 
and  is  first  noticed  at  the  edges  of  the  hair  and  upon  the  wrists 
as  hard,  shot-like  papules  beneath  the  skin.  With  the  appear- 
ance of  the  eruption  the  fever  falls  to  normal  and  there  is  a  sub- 
sidence of  all  distressing  symptoms.  The  eruption,  after  begin- 
ning on  the  face,  appears  on  the  rest  of  the  body,  and  last  upon 
the  lower  extremities.  It  is  always  thickest  upon  the  face  and 
extremities.  Frequently,  when  the  eruption  is  confluent  upon 
the  face,  the  lesions  may  easily  be  counted  upon  the  body.  On 
the  fifth  or  sixth  day  the  papules  begin  to  change  into  vesicles, 
with  a  slight  depression  or  umbilication  at  the  center.  On  the 
eighth  or  ninth  day  the  vesicles  change  into  pustules.  They  then 
lose  their  depression  or  umbilication,  and  become  oval  or  globu- 
lar in  shape  and  grayish  yellow  in  color,  instead  of  the  clear 
serum  of  the  vesicles.  With  the  formation  of  the  pustules  the 
fever  rises, — the  secondary  fever, — and  the  skin  around  the  pus- 
tules becomes  red  and  inflamed.  The  face  and  eyes  are  swollen, 
and  are  frequently  painful.  There  is  ofttimes  a  return  of  the  de- 
lirium with  the  fever,  sometimes  more  marked  than  at  first.  In 
discrete  smallpox  the  fever  usually  begins  to  fall  by  lysis  at  the 
end  of  thirty-six  hours,  the  pustules  break  and  begin  to  form 


682  THE    SPECIFIC    INFECTIOUS    DISEASES. 

crusts,  and  the  swelling  subsides,  so  that  on  the  twelfth  or  thir- 
teenth day  convalescence  may  be  well  established.  In  a  few  days 
more  the  scabs  begin  to  fall  away. 

The  confluent  form  usually  begins  with  the  same  symptoms 
as  the  discrete  form,  except  that  they  may  all  be  intensified.  The 
eruption  appears  about  the  fourth  day,  either  running  together 
or  the  pustules  may  coalesce  later.  The  fever  falls  to  near  nor- 
mal with  the  appearance  of  the  eruption,  and  the  patient  feels 
quite  comfortable.  About  the  eighth  day  the  pustules  are  fully 
formed  or  matured,  and  the  fever  again  rises  to  103°  to  105°  F. 
(39.4°  to  40.5°  C).  With  the  rise  of  the  fever  the  delirium 
often  appears.  Children  are  apt  to  suffer  from  diarrhea,  and 
complain  of  great  thirst.  The  pocks  may  be  seen  in  the  mouth, 
pharynx,  and  air-passages.  This  often  gives  rise  to  a  fetid  dis- 
charge, and  when  in  the  larynx,  to  huskiness  of  the  voice  and 
sometimes  edema  of  the  glottis.  At  this  stage  hemorrhage  may 
take  place  into  the  pustules,  and  exhibit  a  bluish  center — a  very 
unfavorable  symptom,  and  is  sometimes  described  as  a  variety 
of  the  hemorrhagic  form,  or  variola  haemorrhagica  pustulosa. 
The  face  is  swollen,  the  eyes  are  closed,  and  the  lymph-glands 
are  markedly  enlarged.  The  skin  is  painful  and,  tender,  and 
the  itching  is  frequently  annoying.  During  this  stage  delirium, 
subsultus,  and  diarrhea  are  symptoms  of  bad  omen.  When 
recovery  takes  place,  the  pustules  break  about  the  twelfth  or 
thirteenth  day,  and  crusts  begin  to  form.  The  fever  subsides 
about  the  third  week ;  in  severer  cases  about  the  fourth  week. 
Convalescence  is  slow  and  prolonged,  as  a  rule,  and  patients  are 
frequently  tormented  with  numerous  boils. 

VARIOLA  H^EMORRHAGICA. — Hemorrhagic  or  black  smallpox 
presents  nearly  the  same  symptoms  during  the  initial  stage  as  vari- 
ola vera,  but  they  are  all  more  marked  and  severer.  Frequently 
on  the  second  day  a  hyperemic  condition  of  the  skin  appears, 
ecchymotic  spots  show  on  the  conjunctiva,  and  bleeding  fre- 
quently occurs  from  the  mucous  surfaces.  Death  usually  results 
before  the  variolous  eruption  appears.  However,  the  shot-like 
papules  may  be  felt  at  the  edges  of  the  hair  and  upon  the 
wrists. 

VARIOLOID. — The  initial  symptoms  of  smallpox  modified  by 
vaccination  may  be  intense,  but  with  the  appearance  of  the 
eruption  they  all  subside  and  the  patient  is  practically  well. 
The  eruption  consists  of  a  few  papules  scattered  over  the  body. 
It  runs  a  shorter  and  milder  course,  and  the  crusts  separate  much 
sooner  than  in  the  unmodified  variety.  Some  of  the  papules 
never  develop  pustules,  and,  as  a  rule,  there  is  no  secondary 


VARIOLA.  683 

fever.  This  variety,  however,  is  sometimes  very  difficult  to 
diagnose. 

COMPLICATIONS. — Digestive  System. — Vomiting  or  anorexia  is 
frequently  met  with  early.  Swallowing  is  sometimes  difficult, 
owing  to  the  swelling  of  the  glands  and  the  lesions  located  in 
the  throat  and  mouth.  Diarrhea  is  frequently  a  serious  compli- 
cation. Sometimes  lesions  in  the  rectum  give  rise  to  symptoms 
of  dysentery. 

Circulation. — The  pulse  is  full  and  rapid,  not  dicrotic.  Myo- 
carditis occurs  occasionally,  but  endocarditis  and  pericarditis  are 
very  rare. 

Respiratory  Tract. — The  mucous  surface  of  the  upper  respira- 
tory tract  is  frequently  the  seat  of  the  lesions,  and  they  give  rise 
to  fetid  discharges.  Pocks  in  the  larynx  may  extend  through 
the  mucous  membrane  and  cause  destruction  of  the  cartilage  or 
give  rise  to  fatal  edema.  Bronchitis  and  bronchopneumonia  are 
frequent  complications.  Lobar  pneumonia  is  unusual. 

The  kidneys  may  show  a  febrile  albuminuria,  but  true  nephritis 
is  rare.  In  hemorrhagic  cases  hematuria  is  sometimes  present. 

Skin. — Numerous  boils  sometimes  follow  and  prolong  con- 
valescence. 

Eye. — Conjunctivitis  is  frequently  noticed,  and  unless  the  eye 
is  kept  clean  and  aseptic,  keratitis  and  iritis  may  follow,  with 
loss  of  sight. 

Pathology. — The  papule  consists  of  a  cellular  infiltration  of 
the  rete  mucosum,  which  soon  undergoes  coagulation  necrosis. 
At  the  apex  of  a  papule  a  vesicle  is  formed,  due  to  the  circum- 
scribed inflammation  and  exudation  of  serum  beneath  the  epi- 
dermis. The  vesicles  contain  serum,  leukocytes,  and  fibrin 
filaments,  and  are  loculated.  There  is  also  a  depression  in  the 
center,  the  so-called  umbilication.  The  pustules  are  formed  by  a 
filling  of  the  reticuli  with  leukocytes.  When  the  pustule  is  con- 
fined to  the  rete  mucosum,  there  is  no  pitting  or  scarring  ;  when 
it  extends  through  the  true  skin,  pitting  invariably  follows.  True 
"  pocks  "  are  found  on  the  skin  and  also  on  the  buccal  mucous 
membrane,  esophagus,  and  larynx,  but  rarely  in  the  stomach, 
rectum,  or  bronchi.  In  hemorrhagic  smallpox  there  is  an  early 
extravasation  of  blood  beneath  the  skin,  into  the  mucous  and 
serous  membranes,  the  parenchyma  of  the  different  organs,  the 
connective  tissue,  and  nerve  sheaths.  There  are  no  true  pocks 
found  in  the  lungs,  but  bronchitis  and  bronchopneumonia  are 
frequently  associated  with  the  disease,  and  also  lobar  pneumonia 
and  pleurisy  occasionally.  The  heart  is  sometimes  the  seat  of 
myocardial  changes,  but  rarely  of  endocarditis  or  pericarditis. 


684  THE    SPECIFIC    INFECTIOUS    DISEASES. 

Small  areas  of  fatty  degeneration  are  found  in  the  liver.  The 
spleen  is  enlarged.  The  kidneys  may  show  a  cloudy  swelling, 
seldom  a  true  nephritis. 

Prognosis. — Prognosis  depends  on  the  type  or  variety  which 
the  physician  meets.  In  the  discrete  form  the  prognosis  is  very 
favorable.  In  the  confluent  form  it  is  grave,  and  in  the  hemor- 
rhagic  form  is  almost  always  fatal.  Varioloid  is  in  most  cases 
followed  by  recovery.  In  children,  however,  it  is  usually  un- 
modified. Out  of  the  5000  cases  reported  by  Wm.  M.  Welch, 
physician-in-charge  of  the  Municipal  Hospital  of  Philadelphia, 
Pa.,  there  were  80  cases  under  one  year  of  age.  Of  these  80 
only  2  had  been  vaccinated,  leaving  78  unvaccinated.  The 
mortality  among  the  unvaccinated  78  was  57,  or  73.07  per  cent. 
These  figures  show  the  high  mortality  among  unvaccinated 
children  under  one  year  of  age,  and  that  smallpox  almost  always 
occurs  in  the  unvaccinated.  From  one  to  seven  years  of  age  : 
404  unvaccinated  cases  were  admitted  and  208  died,  or  51.48 
per  cent.  ;  of  the  35  vaccinated  cases  2  died,  or  5.7  per  cent. 
Up  to  seven  years  of  age  the  death-rate  is  about  60  per  cent, 
among  the  unvaccinated. 

Diagnosis. — In  typical  cases  of  smallpox  the-  characteristic 
initial  stage,  with  the  headaches,  lumbar  pains,  vomiting,  and 
high  fever,  together  with  the  appearance  of  the  eruption  on  the 
fourth  day,  which  is  at  first  papular,  then  vesicular,  then  pustu- 
lar, makes  the  diagnosis  comparatively  easy.  In  some  atypical 
cases  it  is  liable  to  be  confounded  with  varicella  or  chicken-pox. 
The  chief  points  of  difference  are  as  follows  : 

VARIOLA.  VARICELLA. 

Initial  stage  marked.  Initial  stage  absent  or  very  mild. 

Eruption  appears  at  the  end  of  third  or  Eruption  appears  on  the  first  day  as  a 

beginning  of  fourth  day,  and  is  first  vesicle  and  is  not  umbilicated. 

papular,  then  vesicular  and  umbili- 
cated, then  pustular. 

Vesicle  ismultilocular  ;  the  skin  or  cover-  Vesicle  is  unicellular,  and  the  covering  is 

ing   is  very   tough   and   not   easily  very  thin  and  is  easily  broken  with 

broken  with  finger-nail.  finger-nail. 

Vesicle  does  not  collapse  when  pricked  Vesicle  does  collapse  when  pricked. 

with  a  pin. 

Eruption  thickest  on  face  and  extremi-  Eruption   thickest   on   trunk,    especially 

ties.  the  back. 

Various  stages  of  vesicle   at  points  re-  Various  stages  of  vesicle  side  by  side  : 

moved  from  each  other.  some  are  just  appearing,  while  others 

are  beginning  to  form  crusts. 

Runs  course  in  from  five  to  six  days  in  Runs  course  in  from  two  to  five  days. 

mild  cases,  and  in  ten  to  fourteen 

days  in  severe  cases. 

Secondary  fever,  as  a  rule.  No  secondary  fever. 


VACCINIA.  685 

Scarlatina  and  measles  should  not  give  rise  to  any  difficulty, 
and  for  diagnostic  purposes  the  reader  is  referred  to  the  articles 
on  those  diseases.  The  eruption  of  impetigo  contagiosa  may  re- 
semble variola,  but  the  absence  of  the  initial  stage  and  fever  and 
the  superficial  character  of  the  lesion  should  make  the  diagnosis 
plain. 

Treatment. — The  prophylactic  treatment  is  vaccination,  which 
is  capable  of  causing  the  ultimate  disappearance  of  the  disease. 
When  smallpox  occurs  in  private  families,  it  is  earnestly  advo- 
cated that  all  patients  be  sent  to  a  hospital,  on  account  of  the 
extreme  difficulty  in  securing  suitable  isolation  and  protection  for 
the  public.  The  general  arrangement  of  the  room  and  thorough- 
ness in  disinfecting  all  articles  of  clothing,  etc.,  about  the  patient 
should  be  observed,  as  is  advised  in  the  care  of  diphtheria  patients. 
(See  article  on  disinfection  under  Diphtheria.) 

During  the  initial  stage  opium  is  needed  for  the  pains  in  the 
limbs  and  back.  For  the  relief  of  the  vomiting  such  remedies  as 
bismuth,  pepsin,  cerium  oxalate,  cocain,  iced  champagne,  and  bits 
of  cracked  ice  may  be  used.  The  fever  should  be  controlled  by 
the  cold  bath  or  cold-water  sponging.  In  administering  the  cold 
bath  it  is  advisable  to  begin  with  tepid  water  of  90°  or  95°  F., 
and  gradually  reduce  the  temperature  to  75°  or  80°  F.  For 
the  eruption  it  is  advisable  to  keep  patients  in  a  dark  room,  and 
the  application  of  such  lotions  as  a  saturated  solution  of  boric 
acid  on  lint  or  weak  solutions  of  bichlorid  or  carbolic  acid. 
Emollients,  such  as  cold  cream  or  vaselin,  frequently  relieve  the 
itching  and  keep  the  crusts  soft.  The  eyes  should  be  kept  clean 
with  boric  acid  solutions  ;  also  the  nares  and  mouth.  Diarrhea 
is  frequently  a  troublesome  symptom,  and  is  best  controlled 
by  bismuth  and,  possibly,  a  little  opium.  The  diet  should  be 
carefully  adjusted  to  the  needs  of  febrile  states.  For  the  ex- 
treme weakness  whisky  should  be  given.  Quinin  also  is  indi- 
cated, especially  during  the  stage  of  pustulation,  and  when  the 
secondary  fever  is  high. 

VACCINIA. 
Synonym . — COWPOX. 

Vaccinia  is  an  eruptive  disease  occurring  among  cattle,  which, 
when  inoculated  into  the  human  system,  produces  mild  constitu- 
tional symptoms  and  a  local  manifestation  resembling  the.  pock 
of  variola,  and  confers  more  or  less  permanent  immunity  against 
smallpox. 

History. — While  yet  a  medical  student,  Jenner's  attention  was 


686  THE    SPECIFIC    INFECTIOUS    DISEASES. 

called  to  the  fact  that  milkmaids  in  Gloucestershire,  England, 
who  became  accidentally  inoculated  with  cowpox  were  immune 
to  smallpox.  After  thoroughly  investigating  the  matter  and  by 
numerous  experiments  he  was  convinced  that  cowpox  artificially 
produced  in  the  human  system  rendered  it  immune  to  smallpox. 
He  published  his  discovery  to  the  world  in  1798.  Since  then 
vaccination  has  come  to  be  universally  practised  in  all  civilized 
countries,  and,  as  a  consequence,  smallpox  is  at  the  present  day 
robbed  of  its  terrors. 

Varieties  of  Virus. — Formerly,  humanized  virus  was  alto- 
gether used,  but  since  the  introduction  of  bovine  virus  it  has 
almost  entirely  taken  its  place.  Bovine  virus  is  absolutely  in- 
capable of  conveying  syphilis,  which  occasionally  follows  the  use 
of  humanized  lymph.  Whenever  humanized  lymph  is  used, 
great  care  should  be  taken  in  selecting  a  child  who  is  entirely 
free  from  any  syphilitic  or  other  infectious  taint.  The  humanized 
lymph  acts  more  promptly  and  is  not  followed  by  such  severe 
constitutional  manifestations  as  the  bovine  lymph.  When  it  is 
desired  to  get  a  quick  result, — as,  for  instance,  in  a  person  who 
has  been  exposed  to  smallpox, — it  is  advisable  to  use  humanized 
lymph  ;  otherwise  bovine  is  to  be  preferred. 

The  site  for  the  inoculation  usually  selected  is  the  arm,  but  in 
females  it  is  frequently  desirable  to  use  the  leg,  for  esthetic 
reasons. 

Technic. — The  site  should  be  rendered  aseptic  by  scrubbing 
with  soap  and  water  and  then  rinsing  with  sterile  water.  If  any 
antiseptic  were  employed,  it  might  render  the  vaccine  virus  inert. 
After  the  site  has  been  cleansed,  it  should  be  dried  with  a  clean 
cloth,  and  then  gently  scratched  or  scarified  with  a  sterile  needle 
or  lancet  until  the  site  is  bathed  with  serum.  Avoid  drawing 
blood,  if  possible.  The  technic  is  the  same  for  both  humanized 
and  bovine  lymph  up  to  the  point  of  applying  the  virus. 

1.  Glycerinized  Lymph. — Break  off  each  end  of  the  capillary 
tube,  and  on  one  end  place  the  small  rubber  bulb  that  is  always 
supplied,  and  hold  the  other  over  the  spot  that  has  been  scarified, 
then  press  the  bulb  and  force  out  the  virus,  rub  it  in  thoroughly, 
and  dry  in  the  air. 

2.  Ivory  Points. — Dip  the  ivory  point  into  tepid  sterile  water 
and  thoroughly  rub  it  over  the  place  to  be  scarified  for  vaccina- 
tion.     Instead  of  using  the  needle  or  lancet  to  scarify,  it  may  be 
done  with  the  ivory  point.     After  vaccination  the  serum  should 
be  permitted  to  dry  in  the  air. 

j.  Arm-to-Arm. — A  well-developed  vaccine  vesicle  is  selected 
at  about  from  the  fifth  to  seventh  day  before  the  areola  is 


VARICELLA.  687 

formed.  Some  of  the  serum  is  transferred  from  this  and  well 
rubbed  in  the  same  way  as  above. 

^.  Crust  or  Scab. — A  vaccine  crust  or  scab  taken  from  a  healthy 
child  is  selected.  A  small  piece  is  placed  between  two  pieces  of 
glass  and  thoroughly  powdered.  To  this  some  sterile  water  is 
added,  enough  to  make  it  of  the  consistence  of  cream.  Then 
proceed  as  above. 

Certain  physicians  prefer  some  kind  of  dressing  for  the  wound, 
but  it  has  always  seemed  to  us  that  the  best  results  were  obtained 
by  simply  permitting  the  site  to  dry  in  the  air. 

Period  of  Life. — First  vaccination  should  be  done  in  a  strong 
and  healthy  child  at  about  the  third  month.  If  the  child  is  not 
strong,  it  may  be  advisable  to  wait  unless  smallpox  is  prevalent. 
The  second  vaccination  should  be  done  when  the  child  has  com- 
pleted its  first  dentition  ;  the  third  about  the  time  of  puberty. 


VARICELLA. 
Synonym . — CHICKEN-POX. 

Varicella,  or  chicken-pox,  is  a  mild,  infectious  disease  of  child- 
hood, the  chief  characteristic  of  which  is  a  papular  rash  rapidly 
changing  into  vesicles  with  pearly  contents,  and  always  appear- 
ing in  successive  crops,  with  slight  constitutional  disturbance. 
Though  quite  a  distinct  entity,  it  bears  a  close  resemblance  in 
many  of  its  symptoms  to  a  modified  form  of  smallpox.  Varicella 
is  distinctly  a  disease  of  childhood,  few  adults  and  those  only 
who  have  been  nursing  or  thrown  into  intimate  and  prolonged 
contact  with  the  patient  being  attacked  by  it.  Its  right  to  a  dis- 
tinct place  in  the  list  of  infectious  diseases,  in  contradistinction  to 
its  being  merely  a  modification  of  variola  (as  is  sometimes  stated), 
lies  in  the  fact  that  varicella  and  variola  do  not  mutually  afford 
immunity,  that  variola  affects  all  ages,  and  that  direct  inoculation 
with  the  virus  of  variola  always  produces  that  disease,  and,  like- 
wise, varicella  inoculation  invariably  (when  the  operation  is  suc- 
cessful at  all)  produces  varicella.  The  disease  occurs  in  epidemics 
and  is  especially  common  in  the  poorer  districts. 

Causes. — Chicken-pox  is  due,  in  all  probability,  to  its  own 
specific  germ.  It  is  contagious,  and  the  infective  principle  retains 
its  vitality  for  a  considerable  period  in  clothing,  bedding,  etc.  It 
may  be  communicated  from  child  to  child  by  direct  contact,  and 
a  third  person  can  also  be  the  medium  of  communication.  The 
period  of  incubation  is  variously  estimated,  a  fortnight  being  the 
average  time. 


688  THE    SPECIFIC    INFECTIOUS    DISEASES. 

Symptoms. — Before  the  outbreak  of  the  eruption  there  is  gen- 
erally experienced  a  feeling  of  slight  indisposition,  some  headache, 
but  no  definite  premonitory  symptoms.  Usually  the  first  notice  of 
the  disease  is  the  appearance  of  the  eruption  itself.  At  or  before 
the  period  of  the  eruption  there  are  loss  of  appetite,  weariness, 
and,  as  the  macules  appear,  fever,  the  temperature  rising  to  101° 
or  102°  F.  (38.3°  to  38.8°  C.).  There  may  also  be  chilliness,  and 
in  very  severe  cases  even  convulsions,  although  they  are  very  rare. 
The  eruption  appears  simultaneously  in  different  parts  of  the  body, 
beginning,  as  a  rule,  in  the  borders  of  the  face,  behind  the  ears, 
and  in  the  edges  of  the  hair,  and  consists  in  successive  crops  of 
rosy  papules,  not  unlike  typhoid  fever,  and  small  bullae  or  blebs, 
which  are  of  the  simple  unilocular  variety,  not  umbilicated  as  in 
variola,  or  very  rarely  so.  The  base  of  the  vesicle  is  inflamed, 
and  there  is  a  slight  aureole  of  flushed  skin  around  the  papule. 
The  vesicles  contain  a  limpid,  pearly  fluid  which  remains  fairly 
clear  unless  irritated,  as  by  scratching,  when  it  is  liable  to  become 
purulent  or  ulcerative.  Usually  the  vesicles  dry  up  in  a  few 
hours  and  a  scab  forms,  which  ultimately  falls  off,  leaving  a  clear 
unscarred  skin  underneath.  This  is  the  normal  termination  of 
the  varicella  eruption,  though  it  not  infrequently  happens  that  a 
scar  similar  to  the  scar  of  smallpox  is  left  behind.'  The  succes- 
sive crops  of  vesicular  papules  last  about  a  week,  although  the 
disease  itself  is  over  in  half  that  time.  If  pricked,  the  vesicles 
collapse.  The  number  of  these  vesicles  over  the  body  varies 
greatly,  sometimes  being  few  in  number  and  at  other  times  quickly 
dispersed  over  the  entire  body  ;  the  face,  however,  having  a 
much  smaller  number  in  proportion  to  other  parts. 

Diagnosis. — As  already  stated,  modified  smallpox  may  be 
mistaken  for  varicella.  The  principal  points  of  differential  diag- 
nosis are  as  follows  : 

VARICELLA.  MODIFIED   SMALLPOX    OR  VARIOLOID. 

1.  Incubation  about  fourteen  days.  I.  Incubation  twelve  days. 

2.  Premonitory  symptoms  slight.  2.  Severe,  with  high  temperature,  intense 

backache,  vomiting  ;  all  the  symp- 
toms of  a  severe  disease. 

3.  Premonitory  fever  lasts  but  a  few  hours.       3.  Lasts  two  or  three  days. 

4.  Temperature-rise  slight.  4.   Temperature     rises     suddenly     and 

reaches  its  height  when  papule  is 
fully  developed,  after  which  tem- 
perature falls.  No  secondary  fever. 

5.  Rosy  spots,  macules  becoming  vesic-       5-   Red,  shot-like  papules  appearing  on 

ular  in  a  few  hours  and  drying  in  face,  anus,  and  mucous  membranes, 

three    or  four  days,  leaving   crusts.  In    one    or    two  days   the    papules 

Eruption    comes    out   in  crops  and  change  to  vesicles,  and  on  the  eighth 

spots    and    is    not    confluent.      No  day  develop  into  pustules, 
pustules. 


MALARIAL    FEVER.  689 

VARICELLA.  VARIOLA. 

1.  Appears  chiefly  in  children.  I.   Attacks  persons  of  any  age. 

2.  Duration  of  disease  short,  and  symp-       2.    Period  of  invasion  three  days  ;  general 

toms  very  mild.  symptoms  severe. 

3.  Eruption  papular  or  vesicular  :   never       3.   The  papular  stage  is  longer,  and  the 

pustular.  eruption    ends    with    formation    of 

pustules. 

4.  The  eruption  is  superficial,  rarely  um-       4.   Eruption    is    deep-seated    and   hard, 

bilicated,  not  partitioned,   multiloc-  usually    umbilicated,     the     vesicles 

ular,  and  discrete.  being    partitioned    and     frequently 

confluent. 

5.  Eruption    appears    chiefly    on    hands       5.  Eruption  chiefly  on  face,   hands,  and 

and  feet,  very  little  on  face.  feet. 

6.  Not     influenced    by    vaccination    or       6.   Prevented  by  vaccination  or  previous 

previous  attack  of  smallpox.  attack  of  smallpox. 

Delicate  children  should  be  isolated.  Those  attacked  should 
be  carefully  guarded. 

The  prognosis  is  invariably  favorable.  In  unhealthy  children, 
especially  those  affected  with  scrofula  or  tuberculosis,  the  vesicles 
often  degenerate  into  ulcers,  and  these  may  spread  and  take  on 
a  serious  aspect. 

Treatment. — Chicken-pox  calls  for  very  little  treatment,  but 
it  is  of  more  importance  to  insist  upon  rest  and  freedom  from 
exposure  than  is  ordinarily  taught  or  practised.  While  it  is 
perfectly  true  that  children  suffering  from  this  minor  exanthem 
are  usually  permitted  to  run  about  and  disport  themselves  much 
as  they  like,  upon  the  assumption  of  the  parent  or  physician 
that  the  dangers  of  complication  are  small,  yet  it  is  certainly 
true  that  complications  do  arise,  sometimes  seriously  affecting 
organic  integrity.  A  child  suffering  from  chicken-pox  should 
be  isolated  at  least  for  a  week,  and  kept  under  uniform  and  con- 
trollable conditions  of  air  and  temperature,  thoroughly  protected 
from  chill,  exposure,  or  undue  fatigue,  supplied  with  a  simple 
dietary  and  a  diuretic  and  diaphoretic,  and  go  early  to  bed. 
During  convalescence  definite  control  should  still  be  exercised 
over  fatiguing  conditions,  exposure  to  extremes  of  heat  or  cold, 
and  some  attention  given  to  the  digestive  organs  and  dietetics. 
Some  poverty  of  the  blood  is  liable  to  result  from  even  so  slight 
a  febrile  process  as  this,  and  a  tonic,  with  change  of  air,  should 
be  supplied  when  convenient  or  obviously  needed. 


MALARIAL   FEVER. 

Malarial  fever,  intermittent  fever,  fever  and  ague,  chills  and 
fever,  and  a  number  of  other  names  are  applied  to  a  variety  of 
febrile,  specific,  and  noncontagious  diseases  caused  by  the  pres- 
ence in  the  blood  of  a  protozoon  known  as  the  hematozoon  of 
44 


690  THE    SPECIFIC    INFECTIOUS    DISEASES. 

Laveran,  also  called  by  Marchiafava  and  Celli  the  plasmodium 
malariae,  and  characterized  by  extreme  anemia,  enlargement  of 
the  spleen,  and  by  fever  with  periodic  intermissions  or  remis- 
sions. 

Causes. — Malarial  fever  is  very  widely  distributed  and  more 
or  less  constantly  present  throughout  the  known  world.  In 
America  it  is  constantly  endemic  in  certain  regions,  as  in  the 
Southern  States  and  here  and  there  in  the  Central  States,  espe- 
cially in  lowlands  near  the  coast,  along  the  edges  of  salt  or 
partly  salt  estuaries,  and  less  so  on  the  Great  Lakes.  Its  habitat 
also  changes,  appearing  and  disappearing  under  conditions  rec- 
ognizable or  not  Again,  the  intensity  of  the  attack  varies  con- 
siderably in  different  years,  as  does  also  the  type  of  the  disease. 
Swamp  or  marsh  fever,  as  the  disease  is  also  called,  receives  this 
particular  name  because  of  its  prevalence  in  low,  moist,  ill-drained 
districts,  and  it  seems  to  bear  some  relationship  to  man's  occu- 
pation or  interference  with  the  natural  conditions  of  the  locality, 
such  as  the  forming  of  artificial  dams  and  otherwise  interfering 
with  the  course  of  natural  waterways.  The  contagium  seems  to 
be  propagated  through  the  air  as  well  as  in  other  ways  not  clearly 
demonstrated.  At  the  present  time  two  modes  of  transmission 
are  worthy  of  consideration — by  aerial  transfer  and  by  suctorial 
insects,  chiefly  mosquitos.  Laveran  says  it  is  also  possibly 
acquired  through  drinking-water.  Outbreaks  of  chills  and  fever 
occur  at  special  seasons,  usually  the  late  summer  and  autumn, 
although  occasionally  in  the  spring  and  early  summer.  Prevailing 
as  it  does  in  tropical  climates  constantly,  the  chief  increments  are 
in  the  spring  and  fall.  Laveran  originally  made  known  to  us  the 
specific  micro-organism  which  is  now  recognized  as  the  exciting 
agent  of  malarial  fever,  and  his  researches  have  abundantly  been 
confirmed  by  careful  observers  in  this  country  and  in  Italy,  also 
in  Germany,  South  America,  and  India. 

In  this  country  and  in  Italy  there  are  several  distinct  types  of 
malarial  fever :  First,  mild  forms  of  more  or  less  pronounced 
characteristics,  divisible  into  tertian  and  double  tertian  fever  and 
quartan  fever  and  its  combinations  ;  and  severe  forms,  more  or 
less  irrregular,  occurring  chiefly  in  the  later  summer  and  autumn, 
including  remittent  malarial  fevers,  cases  of  malarial  cachexiae, 
and  certain  pernicious  forms.  In  Italy  these  are  exhibited  in 
several  forms,  but  here  we  see  usually  the  tertian  and  quotidian 
type,  and  a  special  variety  of  micro-organism  has  been  found  to 
accompany  each.  The  morphologic  characteristics  of  the  mala- 
rial parasite  show  it  to  belong  to  the  class  of  protozoa  containing 
a  nucleus  or  one  or  more  nuclei. 


MALARIAL    FEVER.  69! 

Types  and  Variations  of  Malarial  Fevers. — /.  Tertian 
Type  of  Single  Infection. — This  is  the  simplest  form  of  malarial 
infection.  A  single  group  of  organisms  propagate  themselves  in 
the  blood  and  reach  the  stage  of  segmentation  at  about  the  same 
time.  It  has  been  stated  that  the  tertian  type  of  organisms  com- 
plete their  cycle  in  forty-eight  hours. 

2,  The  Quotidian  Type. — If  we  have  what  appears  to  be  a  full 
growth  of  the  organisms  each  day,  as  judged  by  daily  par- 
oxysms, the  quotidian  type  is  exhibited.  Examination  of  the 
blood  from  such  a  case  shows  two  separate  sets  of  organisms  of 
the  same  class,  but  in  different  stages  of  development,  the  first 
maturing  one  day  and  the  second  maturing  the  next  day  follow- 
ing, and  each  producing  a  chill  at  the  time  of  segmentation. 
This,  of  course,  depends  on  a  double  infection  occurring  at  differ- 
ent times.  On  the  other  hand,  the  group  of  the  second  infection 
may  have  been  smaller  than  the  first,  so  that  we  may  for  a  period 
have  only  the  tertian  type  until  such  time  as  the  second  group 
may  grow  to  be  of  sufficient  importance  to  produce  a  paroxysm. 
The  second  group  may  always  remain  smaller,  and  accordingly 
its  paroxysm  will  be  less  severe,  and  it  may  also  mature  at  a  dif- 
ferent hour.  So  we  have  the  clinical  picture  of  a  case  with  ter- 
tian paroxysms  in  a  few  days  becoming  quotidian,  the  second 
paroxysm  being  lighter  and  at  a  different  hour. 

j.  Quartan  Type. — This  depends  upon  the  presence  of  malarial 
organisms  growing  to  segmentation  in  seventy-two  hours,  and 
examination  of  the  blood  will  show,  if  there  is  a  single  infection, 
one  group  of  organisms.  Every  fourth  day  (two  full  days  inter- 
vening) we  have  a  paroxysm  of  from  eight  to  twelve  hours'  dura- 
tion, which  shows  very  little  tendency  to  anticipate  or  retard. 
Quartan  infection  may  be  double  as  well  as  single,  so  that  we  see 
an  attack  coming  on  two  successive  days  with  one  intervening 
day  subject  to  the  same  variations  as  seen  in  the  quotidian,  but 
examination  in  this  condition  will  show  two  sets  of  organisms  at 
different  stages  of  development.  Again,  there  may  be  a  triple 
infection,  so  that  the  period  of  segmentation  comes  daily,  and  we 
now  have  a  quotidian  type,  the  nature  of  which  only  a  blood  ex- 
amination will  settle. 

Paroxysms  are  essentially  the  same  in  both  classes  of  infec- 
tions, whether  it  is  single,  double,  or  triple,  differing  only  as  to 
severity,  which  depends  upon  the  strength  of  the  individual 
groups. 

The  estivo-autumnal  variety  differs  from  the  foregoing  types 
in  its  proneness  to  become  pernicious,  and  depends  for  its  origin 
on  infection  of  the  estivo-autumnal  parasite.  It  presents  itself 


692  THE    SPECIFIC    INFECTIOUS    DISEASES. 

as  a  quotidian,  intermittent,  and  malignant  tertian.  It  is  quite 
irregular  in  its  course,  due  first  to  the  fact  that  the  development 
of  the  different  groups  is  not  completed  at  the  same  time ;  seg- 
mentation is  spread  over  a  longer  period  of  time  (twenty-four  to 
thirty-six  hours),  and  there  is  a  tendency  to  anticipate  segmenta- 
tion ;  and,  secondly,  to  the  factor  of  mixed  infections.  Should  a 
quotidian  intermittent  fever  present  itself,  we  may  be  able  to 
determine  which  type  of  disease  we  are  dealing  with  only  by  a 
blood  examination,  and  since  the  segmentation  is  irregular,  we 
may  clinically  have  at  no  time  a  complete  intermission,  but  a 
remission  and  a  chill  again  preceding  the  rise  of  fever. 

There  is  also  a  malignant  tertian,  in  which  the  temperature- 
curve  makes  a  sudden  ascent,  remaining  high  for  a  number  of 
hours,  fluctuating  but  little,  dropping  part  way  only  to  rise  again, 
and  finally  dropping  to  normal,  the  entire  paroxysm  often  lasting 
thirty-six  hours.  There  is  a  strong  tendency  to  anticipation,  so 
that  the  temperature  may  be  continuous,  presenting  many  of  the 
severe  constitutional  symptoms  which  go  to  make  up  the  clinical 
picture  of  typhoid  fever. 

Pathology. — It  is  a  very  important  and  practical  item  of 
equipment  for  the  physician  to  be  familiar  with  the  methods  of 
clinically  examining  the  blood  in  suspected  malarial  infection. 
The  parasites  found  in  the  blood  of  patients  suffering  from  mala- 
rial fevers  belong  to  the  protozoa.  Different  types  of  the  disease 
present  parasites  with  different  characteristics.  When  the  blood- 
corpuscles  and  the  protozoa  which  they  contain  are  studied,  one 
skilled  in  blood  examination  can  differentiate  the  form  of  the 
disease,  the  frequency  of  .the  paroxysms,  and  also  foretell,  from 
his  knowledge  of  the  life  of  the  protozoa,  the  hour  of  the  com- 
ing of  the  next  paroxysm,  provided,  of  course,  he  knows  the 
hour  of  the  last  one. 

The  blood  should  be  examined  in  the  first  stage  in  dried  un- 
stained films  and  in  dried  stained  films,  each  possibly  having 
certain  advantages.  However,  we  would  recommend  the  use  of 
both  fresh  blood  and  of  dried,  stained  blood.  In  the  fresh  films 
we  should  use  a  small  drop  and  avoid  pressure.  Such  films  may 
further  be  preserved  by  excluding  the  air  by  putting  vaselin  or 
wax  around  the  edges  of  the  cover-glass.  The  chief  advantage 
of  this  method  is  that  it  gives  an  opportunity  to  study  the  ame- 
boid movements  of  the  protozoa,  and  the  disadvantage  is  that 
one  must  examine  it  very  soon  after  withdrawal — at  the  most 
within  three  to  four  hours.  The  stained  films  give  an  oppor- 
tunity for  more  careful  study  of  the  elements  which  are  exhibited 
distinctly  by  the  stain.  Double  staining  with  eosin  and  methyl- 


MALARIAL    FEVER.  693 

blue  or  eosin  and  hematoxylin,  preferably  the  latter,  is  the  most 
satisfactory.  The  method  is  the  same  as  for  ordinary  blood 
examination.  The  blood  should  preferably  be  selected  just 
before  (an  hour  or  so)  the  expected  paroxysm,  though  it  may 
be  taken  at  any  time.  If  it  should  be  observed  just  after  a 
paroxysm,  the  organisms  are  small. 

The  tertian  parasite  completes  its  life  in  about  forty -eight  hours, 
or  less  if  there  is  any  variation  from  this  time.  In  the  first  twelve 
hours  of-  its  life  the  parasites  appear  as  small,  clear  specks  (hya- 
line bodies)  in  the  red  corpuscles,  and  if  any  pigment  is  to  be 
seen,  it  is  as  very  small  granules.  If  stained,  they  appear  pale 
blue.  They  are  actively  ameboid,  and  remain  so  for  about  an 
hour  after  withdrawal.  In  the  next  twelve  hours  the  parasites 
have  grown  to  about  one-third  the  size  of  the  corpuscle,  are  still 
ameboid,  show  fine  granules,  and  the  corpuscle  has  become  paler. 
In  the  next  twelve  hours  the  parasites  have  taken  up  about  two- 
thirds  of  the  cell,  have  become  less  ameboid,  the  granules  larger 
and  moving.  The  parasites  are  now  more  irregular  in  shape,  and 
the  corpuscles  larger  and  paler,  the  pigment  granules  standing 
out  more  markedly.  In  the  next  twelve  hours  all  motion  ceases, 
the  corpuscles  become  shells,  the  centers  of  which  are  occupied 
by  the  parasites,  and  spore  formation  and  segmentation  begin. 
The  organisms  break  up  into  fifteen  or  twenty  round  spores,  at 
first  contained  inside  the  cell-wall  of  the  red  corpuscles,  and 
then  set  free  into  the  blood.  It  is  at  this  time  that  the  clinical 
paroxysm  occurs.  All  hyaline  bodies  do  not  develop  to  the 
stage  of  spore  formation,  nor  do  all  these  spores — really  the 
young  hyaline  bodies — which  have  been  set  free  into  the  blood- 
serum  reenter  the  red  corpuscles,  but  the  blood  plasma  in  itself 
destroys  many  of  them. 

Should  we  have  under  observation  clinically  a  quotidian  form 
of  malaria,  the  red  corpuscles  would  show  the  tertian  parasite 
but  in  two  stages  of  development,  one  group  being  approxim- 
ately twenty -four  hours  older  than  the  other,  of  course  depending 
upon  the  hour  at  which  the  paroxysms  occur.  This  is  due  to  a 
double  infection.  It  must  not  be  forgotten,  however,  that  we 
may  have  a  triple  quartan  infection  that  produces  daily 
paroxysms. 

The  quartan  parasite  grows  in  seventy-two  hours.  In  the 
first  twelve  hours  it  is  a  very  small,  unpigmented,  slightly 
ameboid,  hyaline  body,  becoming  in  twelve  hours  more  about 
the  size  of  one-sixth  to  one-fifth  that  of  the  corpuscle,  having 
taken  on  a  few  pigmented  granules  placed  peripherally.  In 
forty-eight  hours  it  is  one-half  to  two-thirds  the  size  of  the  red 


694  THE    SPECIFIC    INFECTIOUS    DISEASES. 

corpuscle,  round,  as  a  rule,  and  possessing  no  ameboid  move- 
ment. In  sixty  hours  from  the  paroxysm  it  occupies  nearly  all 
of  the  corpuscle,  which  is  neither  enlarged  nor  paler  than 
normal.  In  six  hours  more  the  pigment  granules  approach  the 
center  and  are  arranged  like  the  spokes  of  a  wheel,  the  first  sign 
of  segmentation.  About  three  hours  before  the  attack  segmen- 
tation has  produced  from  six  to  ten  oval  or  pear-shaped  bodies 
or  spores  containing  pigment  in  their  centers. 

In  multiple  infections  of  this  type  we,  of  course,  find  the 
organisms  in  the  blood  in  different  stages  of  development. 

Flagellated  bodies  develop  after  the  blood  is  removed  from 
the  body,  and  consist  of  a  central  cell  with  arms  thrown  out. 
These  arms  are  freely  movable.  In  examining  a  fresh  speci- 
men, we  may  see  such  a  body  keeping  up  a  constant  ciliary 
motion  and  causing  a  disturbance  in  the  arrangement  of  the 
red  cells  in  its  immediate  neighborhood.  The  flagellated 
body  does  not  often  appear  in  either  of  the  foregoing  types 
of  the  infection,  but  is  more  common  in  the  estivo-autumnal 
variety. 

The  second  group  of  parasites  belongs  to  the  class  of  malig- 
nant or  estivo-autumnal  figures,  and  are  divided  into,  first,  the 
pigmented  quotidian  parasite  ;  second,  the  unpigmented  quotidian 
parasite  ;  and  third,  the  malignant  tertian. 

The  pigmented  quotidian  parasite  completes  its  cycle  in 
twenty-four  hours.  When  seen  in  the  blood-corpuscle,  it  appears 
as  a  small,  actively  ameboid,  hyaline  body,  rapidly  becoming 
pigmented  and  quiet,  the  pigment  lodging  in  the  periphery  of 
the  organism,  after  which  it  breaks  up  into  spores.  It  has  been 
pointed  out  that  segmentation  of  this  type  does  not  take  place 
in  the  peripheral  blood,  but  occurs  in  the  spleen  and  bone- 
marrow.  The  pigmented  organism  occupies  one-third  of  the 
corpuscle,  which  is  shrunken,  if  changed  at  all.  After  the  infec- 
tion has  lasted  for  several  days  crescents  appear. 

Crescents  are  always  an  evidence  of  estivo-autumnal  fever, 
and  never  occur  in  the  quartan  or  tertian  type.  They  are  from 
eight  to  ten  micromillimeters  in  length  and  from  two  to  three 
micromillimeters  in  breadth,  are  half-moon  shaped  when  typical, 
but  vary  greatly,  oftentimes  appearing  almost  straight.  They 
contain  pigment,  sometimes  scattered,  but  oftener  found  clumped 
in  the  center,  and  usually  without  motion.  With  a  good  light 
and  an  accurate  adjustment  the  shell  of  the  red  blood-corpuscle 
can  be  seen  extending  from  the  poles  of  the  crescent,  showing 
that  this  parasite  is  distinctly  an  intracellular  formation.  Cres- 
cents are  distinctly  an  evidence  that  the  infection  has  lasted  a 


MALARIAL    FEVER.  695 

number  of  days, — five  or  six, — and  they  will  not  be  found  in 
any  specimen  before  that  time. 

The  unpigmented  quotidian  parasite  shows  not  many  varia- 
tions from  the  foregoing  type,  except  that  it  is  free  from  the 
pigment,  though  the  crescents  formed  from  this  variety  may  show 
pigmentation. 

The  malignant  tertian  parasite  is  pigmented  and,  in  fact,  much 
like  the  pigmented  quotidian.  It  grows  to  segmentation  once  in 
forty-eight  hours,  and  is  ameboid  in  the  advanced  stage  ;  the 
pigment  is  active  and  the  entire  organism  is  larger.  Probably 
no  better  idea  can  be  given  concisely  of  the  different  character- 
istics of  these  parasites  than  by  reproducing  the  table  of  Manna- 
berg's.  (See  p.  696.) 

Pathologic  Anatomy. — In  subjects  dead  of  acute  malarial 
fever  there  are  found  few  characteristic  changes  except  those  of 
the  blood,  as  described  at  some  length  ;  the  brain  shows  little 
hemorrhage,  perhaps  a  few  punctate  hemorrhages,  with  slight 
subpial  edema. 

In  the  milder  forms  of  malarial  fever  there  are  very  slight 
characteristic  changes.  In  the  chronic  forms  there  is  a  malarial 
cachexia,  of  which  anemia  is  the  chief  feature,  with  enlargement 
of  the  spleen,  thickened  and  adherent  capsule,  and  dark  color, 
showing  fibrous  thickening  throughout.  The  liver  is  generally 
enlarged,  and  gray  or  slate-colored  rather  than  brown.  In  death 
from  pernicious  malaria  the  brain  may  show  some  edema  under 
the  pia,  with  evidences  of  hyperemia  and  occasionally  punctate 
hemorrhages,  possibly  due  to  granular  or  fatty  degeneration  of 
the  endothelium  of  the  vessels.  The  malarial  parasites  may  be 
found  in  profusion  in  the  cerebral  capillaries.  The  spleen  in 
these  cases  is  always  large,  the  parenchyma  cyanotic,  and  it  may 
actually  suffer  rupture.  The  liver  is  of  slate-gray  color  usually. 
In  both  these  organs  the  capillaries  are  filled  with  leukocytes, 
and  many  malarial  parasites  can  be  found.  The  kidneys  show 
relatively  few  plasmodia. 

Symptoms. — The  milder  forms  of  intermittent  fever — those 
which  are  commonly  seen  in  the  temperate  zone  and  warmer 
countries,  especially  in  the  spring  and  early  summer — are  the 
tertian  and  quartan  fevers,  each  with  certain  variations.  Tertian 
intermittent  is  the  form  usually  seen  in  this  country.  The  quartan 
is  very  rare,  and  may  be  differentiated  by  blood  examinations. 
The  outbreak  of  fever  and  ague  is  due  to  the  invasion  of  the 
blood  by  a  specific  organism,  which  passes  through  its  cycle  of 
existence  in  forty-eight  hours.  The  febrile  paroxysm  occurs 
when  the  protozoa  reach  their  height  and  begin  to  segment,  the 


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696 


MALARIAL    FEVER.  697 

process  repeating  itself  with  much  regularity  at  intervals  of  forty- 
eight  hours.  In  very  young  children  the  stage  of  chill  is  replaced 
by  mere  restlessness,  cyanosis,  and  cold  extremities,  with  yawn- 
ing, nausea,  or  possibly  diarrhea,  and  along  with  these  various 
motor  nervous  phenomena — twitching  or  convulsions.  In  the 
second  or  hot  stage  the  fever  may  rise  very  high — to  108°  F. 
(42. 1  °  C.)  ;  the  child  is  restless,  thirsty,  and  the  face  is  flushed,  the 
skin  is  hot,  the  eyes  are  injected,  the  pulse  is  full  and  rapid,  severe 
pain  is  felt  in  the  head,  back,  and  limbs,  and  the  urine  is  scanty  and 
of  dark  color.  This  febrile  condition  remains  for  an  hour  or  two, 
gradually  falling,  and  a  profuse  sweat  follows.  In  this  stage  the 
fever  and  pain  gradually  subside,  and  the  patient  falls  asleep, 
from  which  he  awakens  feeling  well.  In  older  children,  beyond 
six  or  seven  years,  the  paroxysm  is  very  similar  to  that  in  adults, 
chills,  fever,  and  sweating  being  well  marked.  Fever  may  reach 
108°  F.  (42. 1  °  C.),  lasting  from  a  few  minutes  to  an  hour.  During 
the  stage  of  the  fever  there  are  great  thirst,  dryness  of  the  skin, 
fretfulness,  headache,  and,  possibly,  also  a  repetition  of  the  diges- 
tive disturbances.  Finally  comes  the  stage  of  sweating,  immedi- 
ately following  which  there  is  evidence  of  exhaustion,  but  soon 
after  prompt  return  to  ordinary  health.  As  in  most  other  acute 
febrile  processes,  instead  of  the  chill  occurring  as  in  adults,  the 
child  suffers  a  convulsion.  Sometimes  the  first  symptom  (so  well 
remembered  by  one  of  the  authors  during  a  long  attack  of  inter- 
mittent fever)  is  scarcely  recognized  chilliness  ;  if  accompanied 
by  blueness  of  the  nails,  it  means  the  onset  of  a  paroxysm.  If, 
as  rarely  happens,  the  case  is  one  of  pure  tertian  fever,  the  child 
seems  absolutely  well  on  alternate  days.  A  marked  cachexia 
may  follow  all  forms  of  the  disease,  or  accompany  cases  treated 
inadequately,  or  wherever  the  sufferer  has  become  subject  to 
repeated  attacks.  Here  the  fever  may  be  slight  or  scarcely 
recognized,  but  the  child  exhibits  a  woeful  appearance,  with  pale, 
sallow  skin,  pinched  features,  sunken  eyes,  irritable  digestion, 
and  recurrent  diarrhea.  Pernicious  malarial  fever,  rare  in  tem- 
perate climates,  exhibits  the  ordinary  phenomena  greatly  inten- 
sified, especially  the  neurosal  features — convulsions  and  pupillary 
changes,  passing  into  coma  and  collapse  or  death,  with  possibly 
little  or  no  rise  in  temperature.  Bronchitis  is  a  common  com- 
plication, and  acute  coryza  has  been  known  to  replace  the  sweat- 
ing stage.  In  children  it  is  usual  to  note  disturbances  of  the 
alimentary  canal  as  the  most  conspicuous  feature  of  the  infection. 
Diarrheas  are  probably  due  to  secondary  infection  in  children 
whose  health  has  thus  been  lowered.  There  is  little  disturbance 
of  circulation,  except  the  vasomotor  changes  seen  during  the 


698  THE    SPECIFIC    INFECTIOUS    DISEASES. 

paroxysm.  Slight  albuminuria  is  observed  occasionally,  and 
hematuria  rarely.  A  number  of  organic  complications  are 
alluded  to,  and  doubtless  are  the  results  of  malarial  infection, 
but  not  directly  due  to  it ;  they  are  rather  evidences  of  devitali- 
zation,  blood  dyscrasia,  and  lowered  resistance. 

Diagnosis. — The  periodicity  of  the  attacks,  requiring  careful 
observation  to  determine  ;  evidences  of  enlarged  spleen,  which 
always  occurs  after  a  few  attacks  ;  and,  finally,  the  presence  of 
the  malarial  organisms  in  the  blood,  will  render  the  diagnosis  of 
malarial  fever,  even  in  children,  most  complete.  Osier  says  that 
widening  experience  strengthens  the  conviction  that  the  value  of 
Laveran's  discoveries  of  the  hematozoa,  demonstrable  in  the 
blood,  is  only  secondary  to  the  finding  of  the  bacillus  of 
tuberculosis  by  Koch,  It  is  not  always  easy  to  make  the 
diagnosis  from  the  clinical  picture.  The  commonest  type  is  the 
double  tertian  or  quotidian  fever.  The  disorder  most  likely  to 
be  confounded  with  this  is  tubercular  infection.  It  must  be 
remembered,  however,  that  the  one  may  be  superadded  to  the 
other.  The  greatest  difficulties  in  diagnosis  occur  in  the  more 
irregular  and  remittent  forms  and  in  the  malarial'  cachexia. 
Here  there  is  the  inevitable  confusion  outgrowing  from  the  dis- 
turbed organic  activities,  of  which  malarial  fever  may  have  been 
the  cause.  Certainty  can  only  be  reached  by  blood  examination 
or  a  practical  conviction  by  the  less  scientific  but  easy  method  of 
applying  the  therapeutic  test — giving  quinin  and  noting  the  result. 

The  prognosis  of  malarial  fever  is  good  enough  if  recognized 
and  adequately  treated.  Failing  in  this,  mild  cases  often  go  on 
to  spontaneous  recovery.  In  severer  cases  the  intensity  of  the 
outbreaks  gradually  diminishes  and  anemia  or  a  chronic  cachexia 
becomes  established  ;  or,  again,  the  paroxysms  may  augment, 
pass  into  the  pernicious  type,  and  produce  collapse  and  death. 

Treatment. — Prophylaxis  is  the  most  important  measure  and 
will  accomplish  much,  provided  the  physician  is  patient  and  per- 
sistent in  his  efforts  and  the  family  is  possessed  of  wisdom,  which 
here,  as  elsewhere,  is  rarer  than  gems.  Keeping  the  child  indoors 
after  sundown  in  a  malarial  locality,  especially  when  the  disease 
is  prevalent,  as  during  spring  and  fall,  is  imperative  and  effica- 
cious. Bedrooms  should  be  upon  the  second  floor,  at  least — 
as  high  up  as  possible.  In  quinin  we  possess  one  of  the  real 
specific  drugs,  and  by  its  use  we  may  confidently  expect  complete 
recovery  in  cases  of  malarial  fever.  The  exceptions  are  rare,  and 
have  to  do  rather  with  individual  hypersusceptibility  to  the  drug 
or  impaired  organic  activity.  The  best  time  to  give  large  doses 
of  quinin  is  immediately  after  a  paroxysm,  and  it  is  usually  well 


MALARIAL    FEVER.  699 

to  do  this  and  follow  with  regular  doses  of  one  or  two  grains 
(0.065  to  1.13  gm.)  three  times  a  day  in  children  under  six  years 
of  age.  George  Dock  emphasizes  the  following  points,  which 
are  in  the  main  embodied  in  the  foregoing  treatment : 

1.  In  tertian,  quartan,  or  any  duplicated  form  of  these  parasites 
the  quinin  should  be  administered  in  the  decline  of  the  paroxysm 
or  before  the  end  of  apyrexia.      The  record  of  the  temperature 
taken  at  frequent  intervals  is  a  very  available  and  safe  guide  to 
the  time  of  administration  of  the  drug.      A  full  dose  of  the  drug, 
in  the  form  of  the  hydrochlorate,  is   administered  in  capsules. 
This  is  followed  after  a  short  interval  by  fifteen  drops  of  dilute 
hydrochloric  acid. 

2.  In  the  estivo-autumnal  form,  where  the   thermometer  fails 
to  show  regular  remissions,  the  symptoms   being  severe,  the 
immediate  administration  of  full  doses  of  the  drug  is  demanded. 
The  fall  of  temperature  or  a  marked  improvement  in  the  sub- 
jective symptoms  following  the  full  effect  of  the  drug  will  indi- 
cate further  treatment,  after  the  manner  of  the  ordinary  tertian 
infection. 

3.  To  prevent  relapses  a  prophylactic  dose  of  quinin  should 
be  given  every  fifth  or  seventh  day  following  recovery — i.  e.,  every 
seven  days  following  a  mild  tertian  ;  every  five  days  following  a 
severe  infection. 

4.  The  general   consensus    of  opinion  is   to  the  effect  that 
hematuria  in  malaria  is   not  a  contraindication  to  the  use  of 
quinin.      Its  cautious  administration  in  small  doses  in  such  cases 
is  certainly  indicated  until  we  have  more  positive  knowledge  that 
it  exercises  deleterious  properties. 

For  sudden  effect  or  in  pernicious  cases  quinin  should  be  given 
under  the  skin  ;  a  form  recommended  for  this  is  the  muriate  of 
quinin  with  urea.  In  ordinary  cases  it  is  better  to  give  the  drug 
distributed  rather  than  in  one  large  dose.  The  difficulties  are  in 
its  disagreeable  taste  and  its  tendency  to  produce  irritability  of 
the  stomach.  The  best  way  is  to  have  the  quinin  in  powder  and 
give  it  in  simple  elixir,  mixing  the  dose  in  each  instance  just 
before  taking.  In  infants  or  where  the  drug  is  not  readily  accepted 
it  may  be  given  by  the  rectum,  at  least  doubling  the  dose  by  the 
mouth.  Jacobi  says  if  the  attack  comes  on  at  regular  intervals 
quinin  should  be  given  at  a  single  dose  two  or  three  hours  before 
the  attack,  a  dose  of  five  grains  sufficing  for  a  child  of  three 
years.  In  attacks  occurring  at  irregular  intervals  there  should 
be  given  enough,  and  a  little  more  than  enough — from  eight  to 
ten  grains  in  three  or  four  doses  during  the  day.  The  neutral 
tannate  of  quinin  is  free  from  much  bitterness,  but  requires  two 


7OO  THE    SPECIFIC    INFECTIOUS    DISEASES. 

and  a  half  to  three  times  the  dose  of  the  sulphate.  For  rectal 
administration  no  acid  should  be  used,  and  the  better  form  is  the 
bromid,  the  muriate,  the  bisulphate,  or  the  carbamid,  and  in  the 
form  of  a  suppository.  Ointments  are  uncertain  or  valueless, 
but  in  extreme  cases  of  susceptibility  may  be  tried  with  lanolin. 
To  disguise  the  taste  of  quinin,  chocolate  or  a  confection  of 
licorice  deserves  a  good  reputation.  Cachets  are  of  use,  but 
children  are  readily  taught  to  swallow  pills  or  capsules  with 
gelatin  or  chocolate  coating,  especially  if  these  be  flattened 
spheres. 

Damonski  reports  very  favorable  results  from  the  use  of 
methyl-blue,  ten  cases  out  of  eleven  terminating  in  recovery  by 
its  use.  He  used  the  drug  for  forty-eight  hours  at  a  time,  and 
then  subjected  the  parasite  at  every  stage  of  its  development  to 
the  action  of  the  drug.  In  chronic  cases  Warburg's  tincture 
has  been  especially  recommended. 

Brodnax  has  found  acetanilid  a  very  useful  agent  to  abort  the 
chills  of  malarial  fever.  This  drug  acts  well  with  quinin  in  some 
cases.  While  administering  quinin,  calomel  in  minute  divided 
doses  is  a  good  adjunct  to  unload  the  upper  bowel  and  thus 
open  the  way  to  the  absorption  of  the  drug. 


EPIDEMIC  INFLUENZA. 
Synonyms. — EPIDEMIC  CATARRHAL  FEVER  ;  LA  GRIPPE. 

In  the  last  few  years  epidemic  influenza  has  obtruded  itself  as 
a  very  important  disorder  in  most  civilized  countries,  and  is  to 
be  found  intermittently  in  nearly  all  parts  of  the  United  States; 
None  of  the  infectious  diseases  deserves  more  prompt  and  intel- 
ligent management,  both  in  prophylaxis  and  in  treatment. 
Complications  and  sequelae  demand  the  most  careful  and  pro- 
tracted attention.  The  facts  that  the  infection  attacks  very 
young  children  with  great  readiness,  that  one  attack  can  not  be 
said  to  protect  against  another,  and  that  the  prostration  is  out  of 
all  proportion  to  the  obvious  organic  disturbance,  make  it  a 
disorder  which  calls  for  the  utmost  persistence  and  positiveness 
at  the  hands  of  the  medical  adviser. 

Epidemic  influenza  may  be  described  as  an  infectious  disease 
attended  by  profound  weakness  and  serious  catarrhal  disturbance 
of  the  respiratory  or  gastro-intestinal  organs  and  many  distress- 
ing and  dangerous  nervous  phenomena.  There  is  no  distinct 
type  of  infantile  influenza,  but  it  seems  marked  by  less  disturbance 
of  the  upper  respiratory  tract,  probably  because  these  parts  are 


EPIDEMIC    INFLUEN7ZA. 

less  exposed  to  chill  and  temperature  changes  than  older  children. 
It  is  remarkable  in  that  it  complicates  some  diseases  and 
appears  to  be  antagonistic  to  others,  notably  scarlatina  and  diph- 
theria. Scarlatina  seems  to  be  subdued  by  it  into  a  very  mild 
form.  With  diphtheria  it  is  apparently  never  associated,  although 
influenza  is  frequently  accompanied  by  a  form  of  sore  throat, 
with  yellow,  pulpy  deposit  in  large  masses,  closely  resembling 
diphtheria ;  but  in  this  is  not  to  be  found  the  Klebs-Loeffler 
bacillus,  and  it  disappears  promptly  upon  treatment,  even  by 
local  measures  only.  In  the  character  of  their  toxic  influence 
diphtheria  and  influenza  have  many  points  of  similarity  ;  the 
extreme  depression,  slowness  of  recovery,  and  susceptibility  of 
nervous  tissue  mark  them  as  much  alike ;  so,  also,  the  influence 
of  these  poisons  upon  the  heart,  with  the  slow  or  irregular  pulse, 
long  maintained  and  sometimes  never  quite  restored. 

Causes. — The  essential  cause  of  influenza  is  now  admitted  to 
be  a  bacillus,  for  whose  discovery  we  are  indebted  to  Pfeiffer,  in 
1892,  and  the  isolation  of  which  is  attended  with  a  good  deal 
of  difficulty.  It  is  a  small,  specific  organism,  resembling  the 
bacillus  of  mouse  septicemia,  but  shorter,  with  rounded  ends. 
The  culture  ground  seems  to  be  mucous  membrane  of  the  nose, 
throat,  and  lungs,  where  it  is  found  in  large  numbers.  The 
earliest  site  of  infection  is  usually  the  throat.  There  are  certain 
contributory  causes  pointed  out,  among  which  meteorologic  con- 
ditions are  mentioned.  The  spread  of  the  disease  is  of  extreme 
rapidity  and  along  the  lines  of  travel. 

The  bacillus  of  Pfeiffer  is  found  only  in  cases  of  influenza.  It 
is  difficult  to  obtain  a  pure  culture.  The  influenza  poison  be- 
longs to  the  group  of  bacterial  proteins  (Buchner) — i.  e.,  poisons 
which  occur  in  the  bodies  of  the  organisms  and  are  not  excreted,  or 
only  to  a  limited  extent,  into  the  media  in  which  they  grow  ;  in 
this  they  resemble  the  diphtheria  and  tetanus  bacilli.  The  toxin 
of  influenza  acts  on  the  central  system  most  powerfully.  Locally 
the  effects  are  exerted  chiefly  upon  the  respiratory  tract  It 
does  not  penetrate  to  any  great  depth,  and  only  very  rarely  enters 
the  blood,  as  shown  by  Cantani's  experiments. 

Mixed  Infections. — The  bacillus  of  Pfeiffer  is  frequently  asso- 
ciated with  other  micro-organisms,  such  as  the  pyogenic  cocci 
and  the  pneumococcus.  The  bacillus  of  influenza  has  been 
cultivated  in  the  presence  of  other  microbes,  especially  the  staphy- 
lococci.  In  cases  of  otitis  media  and  inflammation  of  the  mem- 
branes of  the  brain  the  bacillus  of  influenza  has  been  found  cor- 
related with  staphylococci,  streptococci,  and  pneumococci.  In 
the  pneumonia  of  influenza  some  cases  only  show  the  bacillus 


7O2  THE    SPECIFIC    INFECTIOUS    DISEASES. 

of  Pfeiffer,  others  are  associated  with  the  bacillus  lanceolatus  ; 
most  commonly  the  bacilli  of  influenza  are  found  with  strepto- 
cocci. In  some  cases  there  is  also  associated  the  tubercle 
bacillus  ;  and  sometimes  diphtheria  bacilli  (Wynekoop).  Also 
cases  of  obscure  clinical  manifestation  show  the  influenza  bacillus 
associated  with  those  of  scarlet  fever,  measles,  and  pneumonia. 
This  will  go  far  to  explain  variations  of  symptoms,  since  the 
resulting  toxins  produce  varied  morbid  effects  (Sansom). 

Diagnosis. — If  the  disease  is  not  known  to  be  prevalent,  the 
earlier  cases  are  liable  to  be  overlooked,  unless  of  great  severity. 
Ordinary  acute  catarrhs,  however,  are  rarely  so  severe  or  accom- 
panied by  such  pain  and  prostration,  nor  does  the  process  extend 
to  contiguous  organs.  When  influenza  is  epidemic,  there  is  less 
difficulty  in  recognizing  an  attack,  which  is  marked  by  rapid 
onset,  sudden  and  high  rise  of  temperature,  and  usually  evidence 
of  pain  in  the  head  or  generally  about  the  body  or  in  some 
limited  locality.  Cases  of  sudden  irritability  of  the  stomach  and 
intestines,  accompanied  by  head  pains  and  severe  fever,  may  be 
assumed  to  be  influenza.  From  pneumonia  it  may  be  differenti- 
ated by  the  absence  of  physical  signs  in  the  presence  of  the 
general  symptoms  of  chill,  cough,  etc.  ;  but  very  soon  we  may 
find  actual  pneumonia  as  a  complication,  either  when  it  is  thus 
suspected  or  following  mild  attacks  of  catarrhal  fever,  when  not 
anticipated  ;  and  yet  characteristic  physical  signs  will  be  demon- 
strated upon  search.  Often  the  case  presents  a  complete  picture 
of  pneumonia,  with,  however,  an  absence  of  the  dullness  on 
percussion,  when,  in  true  pneumonia,  auscultation  would  have  led 
us  to  expect  it. 

Influenza  resembles  measles  in  its  onset,  both  in  catarrhal 
symptoms  and  sometimes  in  the  rash.  At  other  times  scarlatina 
is  simulated  by  the  throat  symptoms,  along  with  a  scarlatinal 
rash,  both  usually  of  short  duration.  When  the  lung  symptoms 
or  the  febrile  movements  are  protracted  and  severe,  miliary 
tuberculosis  may  be  feared.  Typhoid  fever  closely  resembles 
catarrhal  fever,  even  in  the  matter  of  eruption  ;  but  the  rose- 
colored  spots  in  catarrhal  fever  are  more  numerous,  extend  over 
larger  areas,  persist  longer,  and  remain  as  slightly  brown  dis- 
colorations  for  some  time  after  fading.  The  fever,  moreover,  is 
more  irregular  than  in  typhoid,  nor  do  we  see  the  apathetic  face 
so  constantly,  the  countenance  being  flushed  in  influenza  and  pale 
in  typhoid.  The  mind,  moreover,  is  clear  ;  the  temper  is  often 
irritable.  The  temperature  in  influenza  frequently  shows  an 
evening  fall  and  a  morning  rise  (the  reverse  of  typhoid  progres- 
sion), and  often  there  are  a  marked  rise  and  fall  at  periods  of  a 


EPIDEMIC    INFLUENZA.  703 

week.  Oftentimes  meningitis  and  influenza  are  scarcely  to  be 
differentiated,  though  in  true  meningitis  the  muscles  of  the  neck 
and  back  exhibit  a  characteristic  and  intense  rigidity,  of  a  per- 
sistence not  seen  in  catarrhal  fever.  The  diagnosis  may  be 
delayed  during  the  progress  of  ill-defined  and  mild  symptoms, 
but  is  made  known  by  the  feebleness  of  the  child  during  con- 
valescence, especially  by  a  weak,  irritable  heart  and  disabilities 
of  various  sorts,  especially  for  sustained  exertion. 

Upon  the  gouty  subject  the  influenza  poison  produces  peculiar 
and  perplexing  symptoms,  modifying  in  some  adverse  way  the 
faulty  metabolism  in  those  so  disposed.  If  added  to  acute 
rheumatism,  it  is  a  serious  combination,  and  may  profoundly 
aggravate  existing  lesions  of  the  heart,  previously  unsuspected. 
Sansom  is  of  the  opinion  that  the  influenza  poison  does  not 
itself  produce  endocarditis,  although  in  a  case  one  of  the 
authors  saw  in  consultation  with  Dr.  Vallandingham,  of  Del- 
aware, a  boy  of  nine,  suffering  from  marked  endocarditis,  had  no 
history  of  rheumatism  or  previous  heart  involvement.  Althaus, 
in  a  study  of  the  influenza  in  the  German  army,  and  Parvinski 
found  only  endocarditis  in  those  not  free  from  suspicion  of  pre- 
vious disorders. 

The  arthritis  which  in  some  cases  accompanies  and  in  others 
follows  upon  influenza  is  probably  a  simulated,  not  a  real,  rheu- 
matism. 

The  relationships  are  exceedingly  puzzling  and  misleading,  but 
seem  to  be  rather  of  the  nature  of  osteo-arthritis  and  have  not 
the  associations  of  true  rheumatism.  There  may  be  rheumatism 
without  painfulness,  as  witness  the  morbid  changes  occurring  in 
the  endocardium  of  the  fetus  without  the  mother  participating  in 
the  disease.  Rheumatic  affections  of  the  heart  often  exhibit  a 
protracted  course  and  show  little  or  no  subjective  symptoms. 

Pericarditis  may  come  and  go  unnoticed,  yet  leave  permanent 
adhesions  and  myocardial  damage.  Endocarditis,  too,  may  be 
accompanied  by  changes  unattended  by  subjective  symptoms, 
such  as  alterations  of  the  endothelium,  formations  of  vegetations, 
exudations,  and  thickenings,  fibrosis,  and  contractions,  calcareous 
deformity  and  degenerations,  lasting  many  months  or  years. 

The  myocardial  changes  may  also  be  profoundly  affected,  the 
whole  heart  being  involved  (the  "  general  carditis  "  of  Sturges). 
(See  Rheumatism.) 

Many  forms  of  nonrheumatic  arthritis  are  known  and  described 
in  connection  with  mumps,  typhoid  fever,  dysentery,  and  cer- 
tain acute  diseases  of  the  nervous  system.  Scarlatinal  arthritis 
is  not  a  rheumatic  affection.  "The  rheumatic  heart  is  in  a  state 


704  THE    SPECIFIC    INFECTIOUS    DISEASES. 

of  permanent  disease,  long-continued  liability  to  organic  disease  ; 
the  nonrheumatic  heart  of  arthritis  is  affected  with,  or  liable  to, 
disorders  of  its  nervous  mechanism,  but  not  to  essential  or- 
ganic disease  of  the  endocardium,  pericardium,  or  myocardium  " 
(Sansom). 

Prognosis. — Influenza  is  a  very  fatal  disease,  partly  from  the 
virulence  of  the  toxin  generated  in  the  blood,  which  may  kill 
outright,  and  partly  from  the  devitalizing  effects  wrought  upon 
the  great  organs,  and  also  from  its  serious  sequelae  and  compli- 
cations. In  children  these  resulting  effects  are  milder  and  more 
limited  than  in  adults  ;  neuritis  is  rare.  Persistent  nervous  cough 
is  perhaps  the  most  frequent.  Gastric  influenza  with  profuse 
nervous  vomiting  occurs  in  very  young  children  ;  there  is  also 
an  influenzal  dysentery,  most  persistent  and  depleting.  The 
mortality  varies  in  different  epidemics,  and  in  some  of  them  chil- 
dren are  more  affected,  in  others  adults.  Death  results  in  most 
cases  from  paralysis  of  the  diaphragm  (Allyn).  All  kinds  of 
children  are  apparently  attacked  indiscriminately.  So  sudden  is 
the  fatality  that  sunstroke  and  malignant  malaria  or  scarlatina 
may  be  suspected.  The  digestive  and  respiratory  organs  may 
escape,  the  poison  overwhelming  the  nervous  system.  Weaker 
children  naturally  succumb  more  readily.  Robust  children, 
however,  are  frequently  changed  into  frail,  feeble  beings  for  years 
or  for  life. 

Symptoms. — The  usual  form  of  the  influenza  attack  is  a  severe 
catarrh  of  the  upper  respiratory  organs,  often  beginning  with 
sneezing,  sometimes  as  a  laryngitis,  less  frequently  as  a  tonsillitis, 
and  rapidly  extending  to  the  throat  and  lungs,  along  with  pains 
in  the  head  or  elsewhere,  neuralgias  or  myalgias,  disturbances  of 
the  heart  action,  and  extremely  irregular  fever.  The  next  in 
frequency  (perhaps  as  frequently  in  children)  is  acute  gastritis 
or  diarrhea,  or  both,  also  associated  with  pains  and  the  other 
symptoms  described.  The  third  form  depends  upon  involve- 
ment of  the  brain  or  nervous  system.  It  is  manifested  by 
irritability  and  fretfulness  (almost  pathognomonic),  or  there  may 
be  hebetude,  or  rather  apathy,  from  which  the  child  is  easily 
roused,  and  is  then  fairly  bright,  not  slow  and  dull  of  speech  as 
in  typhoid  fever ;  occasionally  convulsions  or  coma  vigil  is  seen. 
At  first  there  may  be  chill  and  delirium,  possibly  a  convulsion, 
and  usually  extremely  rapid,  more  or  less  irregular,  pulse.  At 
once  the  temperature  begins  to  be  flighty  and  may  run  high,  but 
not,  as  a  rule.  There  may  be  a  persistent  temperature  of  101  °  F. 
(38.3°  C.)  or  thereabouts  maintained  for  a  long  time  despite  all 
efforts  to  reduce  it.  This  may  alternate  with  or  soon  be  followed 


EPIDEMIC    INFLUENZA.  705 

by  subnormality.  All  these  three  groups  of  symptoms,  or  so 
many  of  them  as  are  not  masked  by  the  others,  may  occur 
together  or  in  rapid  succession.  Headache  or  other  pain  is 
evidenced  only  by  the  child  putting  his  hand  to  the  suffering 
locality,  or  there  may  be  only  a  tenderness  on  being  touched. 
The  conjunctiva  is  often  irritated,  and  tears  are  secreted  in  excess. 

The  respiratory  catarrh  is  liable  to  extend  alarmingly,  involv- 
ing first  one  lung,  then  the  other,  producing  severe  bronchitis 
or  bronchopneumonia,  which  sometimes  clears  up  unexpect- 
edly or  swiftly  destroys  life,  largely  in  proportion  to  the  not 
to  be  predicted  severity  of  the  toxemia  or  the  resistance  and  vigor 
of  the  child. 

When  the  digestive  organs  bear  the  brunt  of  the  attack,  ex- 
haustion is  from  a  double  cause.  Malnutrition  is  severe,  appe- 
tite is  often  lost  after  the  vomiting  or  diarrhea  is  controlled,  and 
a  wretched  picture  of  collapse  and  emaciation  is  presented. 

Complications  may  involve  any  and  every  organ  in  the  body. 
Tuberculosis  is  liable  to  infect  the  thus  depraved  constitution. 
Middle-ear  disease  often  occurs ;  the  skin  is  also  variously 
affected  by  herpes,  erythema,  and  urticaria.  Rheumatism,  or 
rather  painful  arthritis,  is  a  common  and  distressing  feature.  The 
kidneys  suffer,  but  not  often  severely.  The  bones  are  affected 
occasionally  (a  periosteitis).  Those  children  having  a  tendency 
to  rickets  are  liable  to  develop  it  or  suffer  an  aggravation  of 
usual  complications.  Glandular  enlargements  are  common  and 
persist. 

Empyema  almost  never  follows  upon  the  poison  of  influenza 
unless  complicated  by  other  cocci.  Also  it  is  rare  for  tubercle 
to  follow  the  condition  in  children.  Neuritis  rarely  follows  in- 
fluenza in  children,  whereas  it  is  a  common  sequel  in  adults 
(Curtin).  It  is  an  interesting  fact,  pointed  out  by  Curtin,  that  in 
the  epidemic  of  1889  there  was  a  markedly  inverse  ratio  be- 
tween the  prevalence  of  influenza  and  malaria.  As  the  epidemic 
increased  malaria  lessened  rapidly  in  regions  where  it  commonly 
prevailed,  and  returned  as  the  influenza  subsided. 

As  a  rule,  the  younger  the  child,  the  less  characteristic  are 
the  phenomena.  In  the  very  young  gastric  symptoms  prevail. 
The  spleen  is  sometimes  enlarged  ;  albuminuria  occasionally 
appears. 

Treatment. — Prompt  and  efficient  isolation  with  full  means 
for  disinfection  is  demanded  from  the  start. 

To  this  there  should  be  no  demur  nor  temporizing,  though 
neither  the  public  nor  the  health  authorities  fully  realize  this 
yet.  The  treatment  must  be  symptomatic,  and  among  the  first 
45 


706  THE    SPECIFIC    INFECTIOUS    DISEASES. 

comes  relief  of  pain.  During  the  stage  of  high  fever  repeated 
hot  foot-baths  are  most  grateful ;  and  aconite  tincture,  yz  to  one 
minim,  carefully  watched,  may  be  given  every  ten  or  fifteen 
minutes,  or  soon  to  be  followed  by  the  coal-tar  antipyretics  (for 
only  temporary  use),  and  next  full  stimulation  by  champagne  or 
spirits  in  water,  hot  or  cold,  at  short  intervals  ;  also  concentrated 
foods  until  the  stomach  can  receive  more  substantial  fare.  Full 
feeding  is  to  be  given  soon  and  persistently,  and  the  stomach 
may  well  be  reserved  for  the  purpose  while  gastric  irritability 
continues  ;  medicines  are  better  then  given  hypodermically  or 
by  the  rectum. 

For  the  respiratory  catarrh  a  combination  of  atropin,  morphin 
acetate,  heroin,  or  codein,  in  small  repeated  doses,  gives  great 
comfort.  This  had  best  be  accompanied  by  strychnin  or  digitalin 
to  sustain  the  heart.  Quinin  is  also  indicated,  the  hydrochlorate 
best  and  by  the  rectum.  For  vomiting,  bismuth  subcarbonate 
may  be  given  in  chloroform  or  peppermint  water  or  cinnamon 
water.  For  very  severe  gastritis  cocain  will  often  relieve,  -^  or 
-^j-  of  a  grain  being  given  every  half-hour.  (See  Gastritis.)  A 
prompt  action  from  calomel,  y1^-  of  a  grain  every  half-hour,  is 
certainly  useful  here.  The  hot  foot-bath  helps  this,,  too,  as  does 
mustard  to  the  epigastrium  or  neck. 

Phenazone  is  a  good  analgesic  and  expectorant  for  stronger 
children,  and  this  or  phenacetin,  along  with  sodium  salicylate, 
or,  better,  cinchonidin  salicylate,  every  two  or  three  hours,  will 
relieve  the  myalgia,  but  it  may  derange  the  already  irritable 
stomach.  For  intense  muscle  pains  the  hot-pack  or  steam-bath, 
general  or  local,  is  comforting  ;  for  painful  limbs  external  appli- 
cations of  methyl  salicylate,  followed  by  the  flannel  bandage. 

Convalescents  demand  the  most  watchful,  persistent  care. 
Here  the  great  stand-by  is  strychnin  in  increasing  doses  (up  to 
the  verge  of  toxic  endurance  when  great  depression  persists), 
and  long-continued  tonics  and  nutrients,  persistent  overfeed- 
ing, predigestion,  measured  amounts  of  easily  digested  foods, 
meat-extracts,  tonics  of  various  sorts — hypophosphites,  the 
organic  phosphorus  products,  cod-liver  oil,  and,  above  all, 
change  of  air,  which  is  always  demanded  in  tardy  or  incomplete 
convalescence. 

EPIDEMIC    CEREBROSPINAL   MENINGITIS. 
Synonyms. — SPOTTED  FEVER  ;  MALIGNANT  PURPURIC  FEVER. 

Epidemic  cerebrospinal  meningitis  belongs  to  the  list  of  infec- 
tious fevers  which  occur  epidemically  and  sporadically  ;  it  attacks 


EPIDEMIC    CEREBROSPItfAL,    MENINGITIS.  707 

nuvV  -^ 

not  only  human  beings,  but  animals,  both  those'  in  he?xlth  and 
also,  and  more  readily,  those  who  are  exhausted  by  disease  and 
other  depressing  circumstances.  The  disease  is  characterized  by 
inflammation  of  the  cerebrospinal  meninges,  and  clinically  is  of 
irregular  course.  Adults  as  well  as  children  are  affected,  but  the 
young  are  much  more  susceptible. 

Causes. — Epidemic  cerebrospinal  meningitis  arises  suddenly, 
without  warning,  in  the  form  of  an  epidemic,  which  may  attack 
only  a  few  individuals  here  and  there  in  a  community  or  create 
wide-spread  havoc.  The  specific  cause  is  the  micro-organism 
described  by  Weichselbaum  in  1887,  which  received  little  atten- 
tion until,  in  1895,  Jaeger,  followed  by  Councilman,  confirmed 
his  findings,  and  later,  and  more  fully,  in  1899,  Osier  added  fur- 
ther proofs  that  the  disease  is  dependent  upon  infection  by  the 
diplococcus  intracellularis  meningitidis.  It  is  found  alone,  but 
is  frequently  associated  with  other  micro-organisms,  such  as  the 
streptococcus  and  pneumococcus.  Overexertion,  depressing  men- 
tal or  bodily  surroundings,  poverty,  and  unhygienic  surroundings 
act  as  predisposing  causes. 

Pathology. — If  death  occurs  in  the  earlier  stages  of  spotted 
fever,  the  lesions  are  slight,  but  if  later,  the  appearances  of  the 
meninges  of  the  brain  and  spinal  cord  exhibit  evidences  of  intense 
hyperemia.  If  the  case  has  lasted  somewhat  longer,  pus  is  to  be 
seen  under  the  arachnoid.  This  membrane  appears  cloudy, 
especially  along  the  course  of  vessels  from  which  the  exudation 
doubtless  takes  place.  This  purulent  exudate  covers  not  only 
the  tissues  of  the  convexity,  but  may  extend  to  the  base,  in  the 
meshes  of  the  pia,  and  between  it  and  the  cortex.  A  layer  of 
exudate  can  often  be  found  over  the  greater  part  of  the  spinal 
cord.  The  fluid  in  the  ventricles  is,  as  a  rule,  increased,  and  may 
contain  small  flocculi  of  fibrin.  Hemorrhage  may  likewise  take 
place  in  various  parts  of  the  pia  mater  and  underlying  tissues. 
The  other  organs  of  the  body  are  liable  to  be  affected  in  such  a 
way  as  is  common  to  infectious  diseases,  by  hypostasis,  hemor- 
rhage, and  inflammations  generally.  Septic  involvements  of  the 
joints  are  occasionally  seen,  multiple  abscesses  also,  and  even 
parenchymatous  degenerations  of  the  kidneys,  liver,  and  spleen. 
The  dusky  spots  or  mottling  occasionally  seen,  and  which  give 
the  disease  the  name  of  "spotted  fever,"  may  also  be  found  in 
the  internal  organs. 

Symptoms. — The  characteristic  feature  of  spotted  fever  is  its 
suddenness,  as  if  the  poison  came  out  of  a  clear  sky.  The  pro- 
gression of  the  symptoms  is  very  like  those  of  the  other  forms 
of  meningitis,  except  that  they  are  developed  much  more  rapidly. 


. 

7O8  THE    SPECIFIC    INFECTIOUS    DISEASES. 

01 H 

A  child  in  perfect  health 'is  suddenly  smitten  with  headache  or 
chill,  accompanied,  it  may  be,  by  dizziness,  vomiting,  or  convul- 
sions. If  the  case  is  a  mild  one,  these  features  are  not  so  pro- 
nounced, but  usually  the  earlier  symptoms  are  quickly  followed 
by  stupor,  which  rapidly  develops  into  profound  coma.  Often 
this  coma  is  deep  from  the  beginning,  and  may  alternate  with 
delirium ;  in  the  lesser  cases  a  distressing  restlessness  or  twitch- 
ings  may  replace  both,  accompanied  by  hyperesthesia.  The  head- 
ache may  be  replaced  by  neuralgic  pains,  especially  at  first.  The 
vomiting  is  an  early,  common  symptom  and  cerebral  in  charac- 
ter— a  sudden  gushing-out  of  the  contents  of  the  stomach  and  in 
such  quantity  as  is  almost  unaccountable.  The  pupils  are  unequal, 
generally  dilated  ;  strabismus  is  common,  and  photophobia  is  a 
marked  feature.  The  fever  begins  quite  high  and  runs  up  to 
103°  or  105°  F.(39.4°  to4O.5°C.),  but  not  always  ;  in  some  cases 
it  is  never  very  great  or  may  be  actually  subnormal.  Sudden  rises 
in  temperature  usher  in  serious  symptoms.  Delirium  is  rarely 
absent,  and  varies  from  wild  excitement  to  somberness,  and  in  a 
measure  indicates  the  gravity  of  the  disease.  Tenderness  of  the 
flesh  to  touch  is  common,  extending  down  the  spine  or  along  the 
limbs,  sometimes  localized  to  one  set  of  nerves  and  then  shifting 
elsewhere.  As  in  other  forms  of  meningitis,  retraction  of  the 
head  may  alternate  with  clonic  spasms  and  produce  complete 
opisthotonos  or  merely  local  stiffnesses.  Clonic  spasms  are  fre- 
quently met,  from  a  simple  twitching  to  continued  subsultus 
tendinum,  and  may  be  the  forerunner  of  convulsions.  Kernig's 
sign  is  to  be  found,  as  a  rule.  To  obtain  this,  place  the  patient 
in  a  sitting  posture  and  endeavor  to  extend  the  leg  upon  the 
thigh,  and  it  will  be  found  that  the  flexors  contract,  preventing 
the  straightening  of  the  leg  ;  or,  again,  let  the  child  lie  upon  its 
back  and  flex  the  thigh  upon  the  abdomen,  and  try  to  extend  the 
leg  forcibly,  and  the  flexors  will  be  found  to  contract  and  maintain 
the  leg  at  a  right  angle.  Paralyses  arise,  either  of  central  origin 
or  peripheral,  and  are  transient  or  continued.  The  reflexes  vary 
and  are  not  significant,  except  of  local  disturbances.  Sensory  im- 
pairments, as  of  sight  or  hearing,  occur  temporarily  or  remain,  and 
on  the  recovery  of  the  individual  the  sense  organ  may  be  found 
functionally  destroyed.  Photophobia  is  sometimes  distressing. 
Respiration  is  usually  much  disturbed  and  varies  greatly  :  in  the 
beginning  hurried,  and  later  very  slow  ;  at  other  times  interrupted 
or  jerky,  and  toward  the  end,  in  fatal  cases,  of  the  Cheyne-Stokes 
type.  This  last  must  be  regarded,  however,  as  not  so  hopeless 
a  symptom  in  children  as  in  adults.  Diseases  of  the  lungs  and 
pleura,  also  of  the  heart  and  kidneys,  must  be  constantly  watched 


EPIDEMIC    CEREBROSPINAL    MENINGITIS.  709 

for.  The  pulse  in  cerebrospinal  fever  is  rapid  in  children,  as 
a  rule ;  in  adults,  in  the  later  stages,  it  may  be  slow.  The 
skin  shows  characteristic  mottlings,  usually  of  a  dark  purple, 
and  oval  in  shape,  from  ^  to  ^  of  an  inch  in  diameter,  and 
small  red  and  large  bluish  exudations.  These  do  not  fade  on 
pressure.  Cutaneous  hyperesthesia  is  often  noted,  and  the  skin 
is  sore  to  the  slightest  touch,  either  very  hot  or  in  other  instances 
quite  cool  to  the  hand,  and  sometimes  bathed  in  perspiration. 
Constipation  is  usually  present,  and  should  not  be  neglected. 
Inflammatory  diseases  of  the  eyes  are  often  met,  such  as  iritis, 
keratitis,  and  choroiditis ;  also  diseases  of  the  ear  and  the 
joints. 

Diagnosis. — The  prevalence  of  an  epidemic  of  conditions  re- 
sembling spotted  fever,  along  with  the  development  of  cerebral 
symptoms,  will  awaken  a  grave  suspicion.  If,  upon  examination 
of  the  cerebrospinal  fluid,  the  diplococcus  intracellularis  menin- 
gitidis  is  found,  the  diagnosis  is  established.  Repeated  observa- 
tions of  the  fluid  by  microscope  may  be  necessary,  or,  better,  a 
bacteriologic  examination  will  make  the  matter  certain.  Cerebro- 
spinal fever  may  be  mistaken  for  scarlatina  in  its  very  early  stages 
because  of  the  eruption,  which  in  scarlatina  is  so  often  nonchar- 
acteristic  in  its  distribution.  The  throat  symptoms  and  frequent 
nephritis  are  to  be  differentiated  in  the  latter.  From  other  forms  of 
meningitis  it  is  oftentimes  most  difficult  to  distinguish,  unless  the 
eruption  shows  itself  early  in  its  characteristic  small  red  or  larger 
bluish  or  purplish  spots  which  do  not  fade  on  pressure.  The 
epidemic  form,  also,  is  usually  much  more  abrupt  in  onset,  more 
acute,  and  is  accompanied  by  marked  hyperesthesia. 

Prognosis. — Cerebrospinal  fever  is  one  of  the  most  fatal  dis- 
eases of  childhood  ;  about  one-half  recover,  and,  unfortunately, 
when  recovery  does  take  place,  so  damaged  are  many  of  the  or- 
gans that  the  survivor  is  likely  to  be  lamed  for  life  in  many  ways, 
as  by  deafness,  blindness,  and  local  palsies.  The  complications 
which  may  arise  are  limitless  ;  extensive  ecchymosis  is  an  evi- 
dence of  blood  dyscrasia  and  a  fatal  sign.  Prolonged  high  fever 
and  convulsions  not  only  threaten  life,  but  are  liable  to  leave 
serious  structural  damage  upon  the  brain  and  cord,  with  their 
attendant  results,  as  epilepsy  and  the  like. 

Treatment. — The  general  measures  to  be  employed  are  those 
applicable  to  any  case  of  infectious  disease,  to  which  may  be 
added  the  rational  treatment  outlined  under  simple  cerebrospinal 
meningitis.  The  first  thing  to  be  considered  in  cerebrospinal 
fever  is  preventive  treatment,  over  which  we  may  or  may  not 
have  control,  since  the  contagiousness  of  cerebrospinal  fever  is  not 


/lO  THE   SPECIFIC    INFECTIOUS    DISEASES. 

proved.  During  the  prevalence  of  an  epidemic  children  had  best 
be  guarded  from  contact  with  suspected  cases  and  from  expos- 
ure to  extremes  of  heat  and  cold.  Undue  bodily  and  mental 
fatigue  should  be  avoided,  and  they  should  be  supplied  with  sim- 
ple, well-selected  food.  In  the  use  of  counterirritants  for  the 
treatment  of  this  disease  care  should  be  used  not  to  allow  blister- 
ing, because  the  trophic  changes  are  so  profound  that  healing  is 
delayed  unduly.  There  is  no  specific  remedy,  and  we  can  only 
treat  symptoms  as  they  arise.  The  indications  are  to  relieve 
intense  congestions  and  meet  emergencies.  Absolute  quiet  and 
rest  are  first  to  be  secured.  Dry  cups  applied  to  the  neck  and 
back,  on  each  side  of  spine,  are  of  some  value  to  relieve  internal 
congestions  of  the  meningeal  vessels  ;  ice  to  the  head  and  hot 
baths  to  the  body  will  aid  in  relieving  the  hyperemias  and  will 
mitigate  the  headache.  In  certain  cases  when  there  is  evidence 
of  great  intracranial  tension,  lumbar  puncture  may  afford  much 
relief  to  symptoms,  especially  of  pressure  and  pain.  The  bowels 
should  be  emptied  by  enemata  or  calomel.  Should  the  tempera- 
ture be  above  102.5°  F.  (39°  C.),  cold  sponging  is  indicated,  just 
as  in  any  other  fever  ;  for  hyperthermia  the  cold  pack.  In  view  of 
the  constant  vomiting,  medicines  are  best  administered  by  enema 
or  hypodermically.  Chloral  by  enema,  three  to  five  grains,  and 
ergot  hypodermically,  may  be  used  to  influence  capillary  conges- 
tion. Hyoscin  hydrobromate  seems  of  distinct  value  to  relieve 
muscular  spasms,  restlessness,  and  insomnia,  in  doses  of  g-^-  to 
•g-^j-  of  a  grain,  and  is  less  likely  to  produce  depression  than 
chloral.  Opium  is  one  of  the  safest  and  most  reliable  remedies, 
preferable  in  the  form  of  morphin  hypodermically  (^  to  yL ; 
second  doses,  if  the  first  are  found  to  be  ineffectual,  should  be 
double  the  first),  along  with  hyoscin  hydrobromate  or  atropin. 
During  the  stage  of  convalescence  it  is  important  first  to  use 
whatever  will  aid  in  the  absorption  and  elimination  of  the  sero- 
plastic  or  seropurulent  exudate.  Potassium  iodid  is  usually 
needed,  given  in  lithia  or  other  alkaline  water  or  in  the  solution 
of  ammonium  acetate.  For  this  purpose  also,  as  well  as  to  stimu- 
late intestinal  atony,  turpentine  is  of  value.  Nutrient  tonics, 
especially  cod-liver  or  olive  oil  by  inunction,  along  with  mas- 
sage very  gently  begun,  are  of  great  use  in  the  repair  of  tissue 
waste,  especially  in  the  nerves.  Hot  and  cold  bathings  are 
useful  to  the  weakened  parts,  and  better  than  electricity  for  the 
paralyses. 


MUMPS.  7H 

MUMPS. 
Synonym. — SPECIFIC  PAROTITIS. 

Mumps  is  an  acute  specific  infectious  inflammation,  character- 
ized by  pain  and  swelling  of  the  parotid  glands,  with  occasional 
(rare)  metastasis  to  the  mammae,  ovaries,  or  testicles.  It  runs  a 
definite  course,  and  one  attack  usually  confers  immunity. 

Causes. — The  cause  is  evidently  a  specific  poison,  which  as 
yet  no  one  has  succeeded  in  isolating.  The  germ  enters  prob- 
ably by  the  mouth,  reaching  the  parotid  gland  by  Steno's  duct. 
This  disease  is  observed  in  all  lands,  at  any  time  of  the  year,  but 
is  most  common  in  these  latitudes  during  the  fall  and  winter. 
Males  are  more  liable  than  females,  and  the  most  susceptible  age 
is  between  the  third  and  fifth  years.  The  period  of  incubation  is 
generally  two  weeks. 

Symptoms. — These  vary,  depending  on  the  nature  of  the 
epidemic  and  of  the  individual  attacked.  The  stage  of  invasion 
lasts  from  twenty-four  to  seventy-two  hours.  The  local  symp- 
toms usually  have  a  duration  of  from  eight  to  thirteen  days, 
during  which  time  complications  may  set  in.  The  stage  of 
invasion  is  accompanied  by  a  rise  of  temperature,  malaise,  some 
loss  of  appetite,  and  occasionally  vomiting.  The  first  local  symp- 
tom is  a  pain  in  the  space  between  the  mastoid  process  and  the 
lobe  of  the  ear.  Very  soon  this  painful  spot  increases  in  size, 
until  the  whole  region  around  the  ear  becomes  affected.  As  a 
rule,  the  swelling  begins  in  the  same  place  in  which  the  pain  is 
first  noticed,  and  the  enlargement  becomes  general,  usually  in 
from  three  to  six  hours  after  its  first  appearance.  Both  glands 
are  not  attacked  simultaneously  ;  it  begins  in  one  and  has  time 
usually  to  run  its  course  of  inflammation,  to  be  followed  in  a  few 
days  by  the  enlargement  of  the  second  gland.  Upon  the  charac- 
teristic swelling  and  its  accurate  observation  depends  the  correct- 
ness of  the  diagnosis.  Much  consolation  may  be  derived  from 
the  reflection  that  the  acme  of  the  process  is  attained  very 
quickly  and  is  short  lived.  The  principal  complication  of  this 
disease  is  an  inflammatory  enlargement  of  the  testicles  (orchitis), 
spermatic  cord,  and  inguinal  glands  in  males,  especially  liable 
to  occur  about  the  age  of  puberty,  and  in  females  an  involvement 
of  the  ovaries,  labia  majora,  and  mammary  and  inguinal  glands. 
These  are,  in  our  experience,  rare.  Complications  do  not,  as  a 
rule,  appear  until  the  inflammation  of  the  parotid  gland  has  sub- 
sided. 

Diagnosis. — There  is  but  one  gland  that  lies  around  the  ear, 


712  THE    SPECIFIC    INFECTIOUS    DISEASES. 

— i.  e.,  in  front  of  the  ear  and  following  its  outline,  not  only  ante- 
riorly, but  below  and  behind, — and  when  this  swelling  is  localized 
as  to  this  general  outline,  we  are  dealing  with  only  one  disease — 
parotitis.  It  is  common  to  learn  of  other  cases  in  the  vicinity, 
and  this  helps  the  decision. 

Prognosis. — When  the  inflammation  is  uncomplicated,  the 
prognosis  is  favorable,  one  of  the  chief  dangers  being  edema  of 
the  glottis,  or,  as  occasionally  happens,  the  parotid  gland  may 
break  down,  forming  an  abscess.  When  metastases  arise,  as  to 
the  mammae,  ovaries,  or  testes,  the  prognosis  is  not  so  favorable. 
Although  rare  in  our  experience,  such  conditions  are  painful, 
and  while  considerably  lengthening  the  duration  of  the  disease, 
they  do  not,  as  a  rule,  cause  serious  danger  to  the  individual. 
Still,  the  possible  complication  of  mumps  warrants  great  care 
during  an  attack  to  guard  against  chill,  fatigue,  or  digestive  dis- 
turbances. 

Treatment. — This  is  palliative  and  expectant.  The  diet 
should  be  liquid  for  a  week.  Pilocarpin,  used  in  some  cases 
and  claimed  as  a  specific,  has  met  with  varying  success.  Warm 
or  hot  applications  to  the  swollen  glands,  as  hot  olive  oil  applied 
on  cotton,  will  almost  always  prove  acceptable  to  .the  patient. 
When  the  pain  is  considerable,  small  doses  of  an  opiate,  as 
Dover's  powder,  may  be  given,  combined  with  phenacetin  or 
salol.  The  bowels  should  be  kept  open,  and  when  the  fever  is 
high,  it  may  be  reduced  by  sponging  the  body  with  cool  water 
— 70°  or  80°  F. — or  by  suitable  doses  of  aconite  or  other  febri- 
fuge remedies.  As  a  general  rule,  it  is  well  to  keep  the  child 
quarantined  while  the  disease  is  in  progress,  as  its  infectious- 
ness  can  not  be  questioned  ;  neither  should  parotitis  always  be 
treated  carelessly  as  an  insignificant  disease,  as  occasionally  cases 
of  fatal  gangrene  of  the  parotid  and  cervical  glands  have  been 
reported,  and  Joffroy  has  mentioned  a  case  in  which  peripheral 
neuritis  followed,  with  paralysis  of  the  extremities  lasting  four 
months. 

For  glandular  involvement  the  inflammation  is  relieved  by 
various  local  remedies,  as  lead-water,  laudanum,  menthol,  or 
witch-hazel,  and  the  like.  Ichthyol,  25  per  cent,  in  lanolin,  is 
soothing  and  detergent.  Painting  with  menthol  is  recommended. 
All  measures  should  be  supplemented  by  support  and  rest. 
Packing  in  dry  cotton-wool  answers  very  well. 

To  an  inflamed  testicle,  the  application  of  faradism  is  said  to 
aid  in  preventing  atrophy  after  the  acute  condition  has  lessened 
or  subsided. 


WHOOPING-COUGH.  713 

WHOOPING-COUGH. 
Synonym. — PERTUSSIS. 

Whooping-cough,  or  pertussis,  is  an  acute  infectious  and  highly 
contagious  disease  of  early  childhood,  occurring  sporadically  and 
epidemically,  characterized  by  a  catarrhal  affection  of  the  respira- 
tory tract  and  a  characteristic  paroxysmal  cough  which  threatens 
suffocation.  It  leaves  a  peculiar  vulnerability  of  the  mucous 
surfaces  of  the  bronchi  and  intestines,  which  should  never  be  lost 
sight  of  by  parent  and  physician.  It  spreads  with  great  rapidity 
through  a  community,  especially  in  the  cold  months,  attacking 
the  youngest  most  readily,  and  infecting  nearly  all  those  not 
immunized  by  a  previous  attack.  Such  immunity  is  almost  com- 
plete, second  attacks  occurring  only  as  rare  and  isolated  instances. 
Children  who  are  much  in  the  open  air  or  living  in  well-ventilated 
houses,  as  in  the  wards  of  large  hospitals,  asylums,  and  the  like, 
escape  more  readily  than  when  crowded  in  close  quarters.  Infec- 
tion is  almost  entirely  from  direct  and  immediate  contact,  but  the 
slightest  exposure  at  short  range  will  suffice.  Mediate  contagion 
is  most  unusual.  Whooping-cough  is  an  exceedingly  fatal  dis- 
ease, ranking  in  deadliness  to  infants  next  to  scarlet  fever  and 
diphtheria.  It  affects  babes  under  six  months  with  the  utmost 
readiness,  differing  from  the  exanthemata  in  this  respect ;  indeed, 
its  ravages  are  chiefly  confined  to  children  under  two  years,  and 
it  is  not  of  frequent  occurrence  above  four  years  of  age  and  com- 
paratively rare  after  ten. 

The  essential  cause  of  whooping-cough  is  most  probably  a 
micro-organism,  but  what  this  is  has  not  been  exactly  determined. 
Many  contributory  causes  are  recognized,  of  which  the  age  of  the 
patient,  as  already  mentioned,  is  one  of  the  chief.  A  depressed  state 
of  health  is  another,  and  there  is  some  well-recognized  but  unex- 
plained relationship  between  epidemics  of  measles  and  whooping- 
cough  which  predisposes  those  suffering  or  recovering  from 
measles  to  contract  this  specific  cough.  The  presence  of  any 
other  diseases  does  not  interfere  with  its  acquirement.  Some 
children  are  never  infected,  though  often  exposed  ;  a  few  cases 
occur  late  in  life. 

The  lesions  of  whooping-cough  are  varying  degrees  of  catar- 
rhal inflammation,  affecting  the  mucous  membrane  of  the  upper 
respiratoiy  tract,  especially  the  larynx  and  trachea.  Catarrhal 
enteritis  and  colitis  are  common  sequels. 

Incubation. — A  precise  statement  of  the  period  of  incubation 
is  impossible.  It  is  safe  to  estimate  the  latent  period  as  from 


714  THE    SPECIFIC    INFECTIOUS    DISEASES. 

one  to  two  weeks,  but  the  onset  is  too  gradual  and  the  initial 
symptoms  often  too  ill  defined  to  admit  of  greater  accuracy.  It 
is  probable  that  here,  as  in  many  other  infectious  diseases,  the 
incubation  period  is  variable,  depending  upon  personal  systemic 
conditions  and  susceptibilities  and  perhaps  upon  atmospheric  and 
telluric  conditions  as  well.  Usually  several  days  elapse  before 
the  peculiar  characteristic  whoop  is  heard.  The  infective  period 
also  varies,  from  the  very  beginning  of  the  catarrhal  stage  to  the 
end  of  the  spasmodic  stage  or  cough.  Quarantine  should  be 
insisted  on  for  full  three  months. 

Symptoms. — It  is  important  to  distinguish  between  at  least 
two  stages  of  whooping-cough,  the  catarrhal  and  the  spasmodic. 
Sometimes  a  third  more  arbitrary  stage  is  described,  that  of 
decline.  The  first — premonitory,  catarrhal,  or  feverish — stage 
lasts  a  week  or  more.  The  child  is  "poorly,"  with  slight  fever 
and  a  dry,  ringing  cough.  The  cough  of  this  stage  is  not  materi- 
ally different  from  that  due  to  simple  catarrh,  but  occurs  with 
more  virulence  at  night,  often  keeping  the  patient  awake  and 
struggling  to  repress  the  disagreeable  tickling  sensation  in  the 
throat.  Ordinary  cough  remedies  have  little  effect  in  repressing 
this.  In  the  daytime  the  child  may  be  fairly  well>  perhaps  with 
diminished  appetite  and  not  quite  up  to  normal  health.  Auscul- 
tation of  the  chest  reveals  a  condition  of  bronchitis,  with  a  con- 
siderable number  of  bronchial  rales,  both  dry  and  moist,  but 
there  is  little  evidence  of  secretion  from  the  bronchi.  Gradually 
the  cough  becomes  more  and  more  paroxysmal,  and  the  child 
passes  insensibly  or  gradually  into  the  second  or  convulsive  stage. 
At  the  end  of  the  second  week,  or  it  may  be  after  only  a  few 
days,  the  characteristic  whoop  occurs  ;  the  cough  returns  in  re- 
peated paroxysms  ;  the  onset  of  the  paroxysm  is  very  sudden  : 
a  series  of  rapid  expiratory  coughs  occur ;  these  are  at  once  fol- 
lowed by  a  short  and  distinct  "whoop,"  or  long,  noisy  inspira- 
tion ;  then  succeeds  another  series  of  expiratory  coughs,  similar 
to  the  first,  followed  by  a  louder  "  whoop,"  and  so  on  for  three 
or  four  attacks,  until  the  child  is  quite  worn  out.  The  attack 
frequently  ends  by  severe  vomiting.  It  may  readily  be  seen  how 
forty  or  fifty  such  paroxysms  during  the  course  of  twenty-four 
hours,  many  or  most  followed  by  regurgitation  of  food,  will 
greatly  exhaust  the  child,  and  as  the  disease  continues  for  a  long 
period,  pertussis  is  rightly  to  be  dreaded.  As  has  been  before 
stated,  the  termination  of  a  paroxysm  is  denoted  by  eructation 
and  vomiting  of  bits  of  food,  stringy  mucus,  and  sometimes  small 
quantities  of  blood.  During  the  coughing-fit  the  face  becomes 
dusky  and  cyanosed — indeed,  all  through  this  stage,  owing  to  the 


WHOOPING-COUGH.  715 

frequent  and  severe  coughing,  the  face  presents  a  peculiar  livid 
appearance  and  the  eyes  are  swollen  and  watery.  The  duskiness 
of  the  skin  is  due  to  capillary  congestion,  and  often  there  are 
extravasations  of  blood  into  the  conjunctivae,  the  whole  con- 
junctival  surface  sometimes  becoming  blood-red.  A  sharp  bleed- 
ing from  the  nose  often  accompanies  or  follows  the  paroxysm. 
Sneezing  is  a  common  phenomenon,  sometimes  replacing  the 
cough  for  longer  or  shorter  periods.  After  this  stage  of  four  or 
five,  sometimes  seven  or  eight,  weeks,  the  paroxysms  grow  less 
in  number  and  severity,  the  "  whoop  "  disappears,  the  lungs  clear 
up,  and  convalescence  is  established.  A  slight  ulceration  of  the 
frenum  of  the  tongue  is  often  noted. 

Complications  and  Sequelae. — The  most  common  and  dan- 
gerous complications  of  pertussis  are  bronchitis  and  broncho- 
pneumonia.  These  occur  oftener  in  the  summer  months. 
Atelectasis  of  a  portion  or  the  whole  lung  may  prove  a  fatal 
complication  in  very  young  children,  especially  those  of  stru- 
mous  or  rachitic  type.  Occasionally  pleuritis  with  effusion  or 
croupous  pneumonia  arises  in  the  latter  stages,  and  empyema 
has  been  observed.  Emphysema  is  not  a  very  rare  complication 
where  the  amount  of  coughing  is  great,  but  this  usually  passes 
away  entirely.  A  much  rarer  complication,  and  one  fraught 
with  sudden  and  great  danger,  is  edema  of  the  glottis.  A  num- 
ber of  small  grayish  or  yellowish-gray  ulcers  are  frequently 
found  upon  the  frenum  of  the  tongue,  having  small  significance 
and  bearing  no  relation  to  the  severity  of  the  attack.  While 
vomiting  is  a  symptom  commonly  present  and  usually  ends  a 
pronounced  paroxysm  of  coughing,  it  may  become  of  such 
frequency  and  severity  as  to  endanger  life  by  producing  starva- 
tion. Chronic  diarrhea,  also,  may  be  a  late  and  stubborn  sequel. 
A  certain  amount  of  hemorrhage  from  the  lungs  not  infrequently 
accompanies  the  paroxysm  in  severe  cases,  but  more  often  there 
is  bleeding  from  the  mouth  and  ears.  Cases  of  true  gastric  hem- 
orrhage, while  very  rare,  have  been  reported.  An  effusion  of 
blood  may  also  take  place  into  the  meninges.  Hemorrhage  into 
the  subconjunctival  tissues  is  not  at  all  unusual.  Epistaxis,  fre- 
quently repeated,  tends  seriously  to  deplete  the  sufferer.  The  ner- 
vous sequelae  of  pertussis  are  sometimes  severe  ;  convulsions,  es- 
pecially in  young  children,  may  cause  death,  but  are  not  common. 
Spasm  of  the  glottis,  aphasia,  hemiplegia,  and  loss  of  vision  of  a 
more  or  less  transient  sort,  occur  quite  often.  During  the  attack  of 
coughing  involuntary  passage  of  urine  and  feces  may  take  place, 
and  the  congestion  of  the  kidneys,  which  during  the  disease  is 
always  markedly  present,  may  possibly  result  in  a  true  nephritis, 


7l6  THE    SPECIFIC    INFECTIOUS    DISEASES. 

parenchymatous  in  nature.  This  sometimes  persists  long  after 
the  disease  itself  has  subsided.  Cases  have  also  been  reported 
in  which  diabetes  mellitus  has  followed  the  attack  of  whooping- 
cough.  Glandular  enlargements,  particularly  those  of  the  bron- 
chial glands,  are  not  uncommon.  Relapses  or  recrudescences 
of  whooping-cough  have  been  observed. 

Diagnosis. — In  the  beginning  it  is  practically  impossible  to 
differentiate  whooping-cough  from  ordinary  catarrhal  states  unless 
the  whoop  appears.  When  once  this  is  established,  there  need 
be  no  difficulty.  However,  in  the  absence  of  whoop  a  prolonged 
severe  cough  and  catarrhal  state,  with  freedom  from  fever,  the 
increments  appearing  at  night  and  being  of  a  spasmodic  charac- 
ter, emphasize  suspicion.  Children  may  have  whooping-cough 
yet  never  exhibit  the  characteristic  whoop. 

The  disease  is  probably  of  microbic  origin.  Afanassiew  in 
1887  isolated  a  bacillus  which  he  called  the  bacillus  tussis  con- 
vulsivae,  and  other  investigators  have  substantiated  his  opinion. 
The  germ  has  been  found  principally  in  the  mucus  of  the  trachea. 

Pathology. — Henry  Koplik  first  and,  independently  and  soon 
after,  Czaplewski  and  Hensel  have  recorded  as  constant  in  per- 
tussis a  facultative  anaerobic  bacillus  resembling  in  its  mor- 
phology the  influenza  bacillus,  but  somewhat  larger. 

Vincinzi  also  describes  a  small,  immobile,  coccus-like  bacillus 
resembling  the  influenza  bacillus,  constant  in  a  series  of  cases  of 
pertussis.  Behla  later  came  to  the  conclusion  that  the  exciting 
cause  of  whooping-cough  is  a  micro-organism,  not  of  a  bacterial 
nature,  not  found  in  the  blood  or  epithelium,  and  not  possessing 
an  intracellular  growth,  but  belonging,  as  Deichler  and  Kurloff 
also  believe,  to  the  protozoa,  its  whole  deportment  testifying  that 
it  is  an  ameba,  increasing  by  division  aud  presenting  the  forma- 
tion of  spores. 

The  immediate  cause  of  the  paroxysms  of  coughing  is  un- 
doubtedly a  supersensitive  condition  of  the  mucous  membrane 
of  the  air-passages,  which  is  supplied  by  the  superior  laryn- 
geal  nerve.  There  are  few  pathologic  changes  to  be  found 
postmortem  in  the  various  organs.  Those  most  commonly  seen 
are  due  to  congestions,  especially  in  the  lungs,  heart,  kidneys, 
and  meninges.  Occasionally  after  death  patches  of  atelectasis 
or  pneumonia  are  to  be  found  in  the  lungs  or  hemorrhages  into 
these  organs.  The  pathologic  effects  of  the  poison  are  mani- 
fested chiefly  on  the  nervous  and  the  lymphatic  system. 

Treatment. — The  treatment  of  whooping-cough  should  be 
both  local  and  systemic.  The  infectious  principle  enters  by  the 
upper  air-passage,  and  hence  carefully  directed  and  persistently 


WHOOPING-COUGH.  71  / 

applied  local  remedies  can  be  relied  on  to  modify  or  check  the 
disorder,  and  our  experience  encourages  us  to  believe  this  to  be  a 
most  important  factor  in  treatment.  Children  can  soon  be  trained 
to  submit  to  the  application  of  aseptic  and  soothing  sprays  and 
other  local  medications  :  even  to  welcome  them  for  the  relief  they 
afford.  Those  who  object  should  be  persuaded  or  held  in  posi- 
tion for  intubation,  advised  by  Walter  Freeman.  It  is  well  to 
spray  or  douche  the  nose  with  a  cleansing  solution,  preferably 
alkaline  and  approximating  the  specific  gravity  of  the  blood,  to 
which  may  be  added  various  stimulating  or  astringent  ingredi- 
ents suited  to  the  stage  of  the  disorder  or  the  local  conditions 
of  the  mucous  surfaces,  repeating  several  times  a  day.  This 
may  be  followed  by  oily  sprays  containing  menthol  or  camphor. 
When  relaxation  is  obvious,  astringents  are  indicated,  of  which 
sulphate  of  zinc  or  alum  is  useful,  in  tincture  of  rose  or  pome- 
granate. Later  iodin  in  glycerin  is  of  value  to  alter  the  glandu- 
lar action,  applied  on  a  cotton  swab.  Cocain  and  antipyrin,  in 
weak  solution  in  an  aromatic  water,  applied  to  nose  or  pharynx, 
greatly  relieve  certain  cases.  Cocain  is  not  of  much  use,  how- 
ever. Extract  of  hamamelis  is  of  value.  The  use  of  acidulated 
solutions  of  quinin,  both  locally  and  systemically,  was  suggested 
to  one  of  the  authors  by  Edward  Watson,  and  proved  of  greater 
value  than  any  other  remedy. 

To  relieve  vomiting  Baginsky  recommends  menthol,  from  ^  to 
£  of  a  grain  rubbed  up  in  white  sugar  every  two  hours. 

The  length  and  severity  of  the  spasm  are  greatly  checked  by 
inhaling  a  mixture  of  three  parts  chloroform,  five  parts  ether,  and 
one-half  to  one  part  amyl  nitrite.  A  few  drops  of  this  are  applied 
on  a  handkerchief  and  held  under  the  nose  on  the  instant  of 
coughing,  and  has  proved  of  great  service  in  our  hands  and  never 
gave  rise  to  any  anxiety  ;  indeed,  it  has  apparently  saved  life  often. 
Internally  the  great  remedy  is  quinin,  preferably  in  solution,  with 
hydrobromic  acid.  Thus  is  obtained  both  a  local  and  systemic 
effect,  and  the  dose  is  best  given  at  frequent  intervals  of  not  less 
than  two  or  three  hours.  If  this  does  not  suffice,  atropin  or 
hyoscin  hydrobromate,  in  a  dose  of  y^-fr  to  -g-J-g-  of  a  grain  every 
two  hours,  is  of  value.  Bromoform  is  highly  extolled  by  some, 
especially  the  French,  and  is  of  much  value.  An  opiate  in  the 
form  of  codein  or  Dover's  powder  checks  coughing  best  at  night. 

One  of  the  recent  remedies  much  extolled  is  an  ointment  of 
difluordiphenol,  one  or  two  drams  a  day,  rubbed  into  the  skin. 

To  quote  from  one  of  the  authors,  it  is  important,  "  First,  to 
begin  treatment  as  early  as  possible,  especially  with  local  mea- 
sures. In  certain  instances  I  was  of  the  opinion  that  beginning 


THE    SPECIFIC    INFECTIOUS    DISEASES. 

attacks  were  thus  aborted.  Second,  it  seemed  of  value  to  meet 
the  toxin  by  small  repeated  doses  of  calomel  with  bicarbonate  of 
soda  or  boric  acid,  or  both,  to  expedite  action  of  the  kidneys. 
Third,  the  diet  should  be  simple,  carefully  prepared,  and  given 
in  small  amounts  at  a  time,  so  as  not  to  overload  the  stomach  or 
overtax  the  digestive  capacity  anywhere.  If  vomiting  occurs, 
food  should  be  offered  soon  after, — a  half-hour  or  an  hour, — for 
very  rarely  it  is  accompanied  by  nausea ;  it  is  merely  a  reflex 
spasmodic  rejection  of  food,  and  starvation  is  thus  easily  in- 
duced. For  very  profuse  vomiting  in  older  children  I  occa- 
sionally use  small  pills  of  cocain,  -^j-  to  ^  of  a  grain,  along 
with  two  grains  of  cerium  oxalate.  Fourth,  the  local  mea- 
sures, as  outlined  above,  must  be  promptly,  thoroughly,  and 
frequently  applied.  Fifth,  children  afflicted  with  pertussis  should 
live  all  day  in  the  open  air,  adequately  clothed.  If  the  weather 
is  exceedingly  inclement,  they  may  play  about  in  a  room  with  all 
the  windows  open,  clothed  as  if  for  the  open  air.  Sixth,  the 
question  of  climate  is  a  relative  one  which  can  be  met  within  four 
walls  if  the  proper  conditions  are  obtained.  This  can  be  accom- 
plished by  maintaining  a  proper  temperature  and  relative  hu- 
midity. Too  great  dryness,  if  artificial,  is  distinctly  objectionable. 
Sometimes  the  seashore  is  best,  but  more  often  a  wholesome 
piece  of  woodland  will  suffice,  especially  if  it  consists  largely  of 
the  conifera.  Dry,  sandy  soils  are  much  better  than  alluvial 
ones,  but  there  should  always  be  an  abundance  of  outdoor  air 
both  by  night  and  by  day,  and  as  little  as  possible  of  fatiguing 
conditions,  such  as  school  tasks  induce." 

The  most  potent  factor  in  the  disease,  both  in  children  and  in 
adults,  is  the  spasm  of  the  glottis.  Intubation  by  O'Dwyer's 
tubes  has  been  employed  with  great  satisfaction  to  relieve  pro- 
found spasm  of  the  glottis. 

Norton  tried  the  use  of  carbonic  acid  gas  by  the  rectum  upon 
1 50  cases.  Of  these,  143  were  apparently  benefitted.  The  vom- 
iting ceased  after  the  second  or  third  administration  in  even  very 
severe  cases.  A  slight  diarrhea  resulted  in  a  few  instances, 
attributable  possibly  to  irritation  of  the  rectal  canal. 

Attention  has  been  called  to  the  use  of  vaccination  in  cases  of 
pertussis  ;  it  seems  of  undoubted  value,  especially  in  those  not 
previously  vaccinated,  effecting  a  cure  in  about  two  weeks. 

SYPHILIS. 

Syphilis  is  a  specific  disease,  probably  of  microbic  origin,  of 
slow  evolution,  engendered  by  inoculation  (acquired  syphilis)  or 


SYPHILIS.  719 

by  transmission  from  parents  (congenital  syphilis).  In  congeni- 
tal syphilis  (excepting  only  the  primary  sore  or  chancre)  all  fea- 
tures of  the  acquired  disease  may  be  manifested.  Syphilis  arising 
in  infancy  may,  however,  be  acquired  possibly  from  a  sore  on  the 
genital  tract  of  the  mother,  from  lesions  in  the  nurse  or  attend- 
ant, especially  a  mucous  patch  upon  the  mouth  or  lips. 

A  babe  infected  with  syphilis  may  come  into  the  world  healthy 
looking  or  with  obvious  evidence  of  the  disease  ;  generally  no 
symptom  is  shown  until  a  month  or  more  has  elapsed.  Syphilis 
may  be  acquired  from  the  father  or  mother,  or  from  both,  infect- 
ing through  the  spermatozoa  of  the  male  or  the  ovum  of  the 
female.  It  is  generally  admitted  that  if  infection  arises  from  a 
double  syphilization,  from  both  an  infected  father  and  mother, 
the  result  is  more  disastrous  to  the  offspring.  There  is  the 
greatest  danger  from  paternal  transmission  during  the  first  year 
after  primary  infection,  and  it  is  possible  up  to  the  end  of  the 
fourth  year.  Early  and  thorough  treatment  greatly  lessens  the 
probability  of  transmission,  but  after  a  certain  time  this  immun- 
ity is  lost.  A  mother  may  bring  forth  a  syphilitic  child  without 
herself  giving  evidence  of  having  acquired  the  disease.  Colics' 
law,  well  established,  is  that  a  mother  bringing  forth  a  syphilitic 
child  can  not  acquire  the  disease  from  the  infant,  and,  further, 
she  is  immune  to  syphilis  from  any  source.  If  a  mother  is 
suffering  from  constitutional  syphilis,  the  disease  is  transmitted  in 
an  unusually  active  form  to  her  offspring.  The  degree  of  severity 
depends  upon  the  stage  of  syphilization,  character  of  the  disease, 
and  the  nature  of  the  treatment  employed. 

Symptoms  of  syphilis  at  birth  are  feebleness  of  the  infant, 
malnutrition,  usually  certain  skin  eruptions  in  the  form  of  bullae 
about  the  wrists  and  ankles,  and  pustular  syphilids  on  the  feet 
and  hands,  ulcerated  lips,  nasopharyngeal  catarrh,  and  enlarge- 
ment of  the  liver  and  spleen. 

Early  Manifestations. — (i)  Those  cases  which  develop  the 
disease  at  birth  or  very  early  after  birth  ;  (2)  those  which  develop 
it  one  or  two  months  later. 

I.  When  the  disease  manifests  itself  early  after  birth,  the 
attack  will  be  severer  ;  in  other  words,  the  earlier  the  attack, 
the  graver  the  disease.  The  usual  symptom-group  is  emaciation, 
a  severe  form  of  coryza,  and  an  eruption  of  blebs,  particularly 
upon  the  palms  of  the  hands  and  soles  of  the  feet.  Certain 
fissures  and  ulcerations  appear  on  the  lips,  which  are  character- 
istic and  are  a  source  of  infection  to  wet-nurses.  There  are  also 
signs  of  bony  and  visceral  disease,  disturbances  of  nutrition, 
with  consequent  atrophy  of  all  the  structures  of  the  body,  and 


72O  THE    SPECIFIC    INFECTIOUS    DISEASES. 

the  infant  presents  the  countenance  of  an  old  man.  All  this  is 
due  to  the  direct  influence  of  the  syphilitic  virus.  Skin  erup- 
tions are  similar  to  those  appearing  late  in  the  course  of  the 
disease.  These  children  rarely  survive  long. 

2.  When  a  syphilitic  babe  is  born  seemingly  healthy,  without 
any  sign  of  abnormality,  it  thrives  well,  or  apparently  so,  and 
may  remain  thus  for  a  month  or  two,  when  a  nasopharyngeal 
catarrh  usually  develops,  producing  the  characteristic  snuffles 
and  interfering  seriously  with  the  act  of  nursing.  This  catarrhal 
condition  may  extend  to  the  Eustachian  tubes  or  middle  ear 
and  thus  cause  deafness.  In  the  graver  forms  of  syphilis  the 
discharge  may  be  seropurulent,  evidencing  ulceration  ;  necrotic 
changes  take  place  in  the  bones,  with  local  loss  of  tissue,  pro- 
ducing the  characteristic  flat  nose  of  congenital  syphilis.  The 
protoplasm  of  children  reacts  readily  to  irritative  processes,  and 
the  syphilitic  poison  produces  extensive  changes  and  ravages  in 
the  tissue  ;  hence,  the  very  remotest  parts  are  affected  and  with 
a  wide  variety  of  phenomena.  The  skin-lesions  develop  along 
with  or  soon  after  those  of  the  mucous  membranes.  One  of  the 
earliest  is  the  eruption  of  small,  round,  or  oval  pink  macules, 
disappearing  on  pressure  and  occurring  upon  the  lower  part  of 
the  abdomen  or  nates,  spreading  thence  over  most  of  the  body. 
The  color  of  the  erythematous  rash  has  a  tendency  to  become 
like  that  of  copper,  and  yet  the  resemblance  to  a  simple  erythema 
is  very  close.  Usually  there  is  little  or  no  scaliness,  except  at 
times  on  the  hands  or  feet ;  at  others  this  eruption  tends  to  grow 
worse,  showing  moist,  infiltrated  patches,  closely  resembling 
eczema. 

A  papular  syphiloderm  usually  accompanies  the  erythema,  in 
the  shape  of  small,  dull,  red  papules  running  together.  When 
lesions  occur  near  the  mucous  orifices,  especially  about  the  anus 
and  commissures  of  the  lips,  condylomata  may  result  and  are 
highly  contagious.  There  may  also  form  rhagades  or  linear 
scars  radiating  from  the  mucous  junctures.  Pustular  syphilo- 
derms  begin  as  early  as  the  eighth  week,  but  usually  later. 
The  pustules  may  be  large,  numerous,  and  deep,  or  few  and 
small,  varying  with  the  severity  of  the  case.  The  sites  selected 
are  the  face  and  buttocks,  the  lesions  resembling  impetigo  or 
pustular  eczema.  The  syphilitic  pustules  or  crusts  are  dark, 
thick,  and  greenish,  forming  deeper  ulcerations  than  impetigo, 
and  the  itching  of  eczema  is  absent.  Occasionally  a  furunculoid 
eruption  occurs,  especially  in  ill-nourished  children,  the  lesions 
beginning  as  small  nodules  in  the  corium,  increasing  greatly  in 
size,  throwing  off  irregular  sloughs,  and  leaving  unhealthy  cavi- 


SYPHILIS.  721 

ties  and  resulting  in  cicatrices.  Bullous  and  tubercular  eruptions 
are  seen  occasionally  in  syphilitic  children  (pemphigus),  the  skin 
showing  at  first  a  violaceous  patch  ;  soon  after  vesicles  appear, 
becoming  confluent,  running  together,  and  growing  larger. 

The  viscera  are  apt  to  be  more  extensively  involved  in  con- 
genital than  in  acquired  syphilis.  The  lesions  are  less  likely  to 
be  gummatous  than  interstitial,  the  hyperplasia  being  more  or 
less  diffuse.  The  interstitial  connective  tissue  in  the  process  of 
overgrowth  and  subsequent  contraction  shrinks  the  parenchyma. 
The  lung,  or  a  portion  of  a  lobe,  may  present  a  profuse  fibroid 
infiltration.  The  spleen  is  usually  more  or  less  enlarged,  and 
the  capsule  is  thickened.  The  liver  not  seldom  is  enlarged  and 
hardened,  from  a  profuse  sclerosis  ;  art  interstitial  orchids  may 
affect  one  or  both  testicles,  producing  a  hardening  and  enlarge- 
ment of  the  glands.  General  nephritis  is  an  occasional  intercur- 
rence.  There  are  two  principal  ways  in  which  syphilis  affects 
the  bones  in  early  life,  usually  the  long  bones — the  one  pro- 
ducing changes  at  the  junction  of  the  shaft  (diaphysis),  the  other 
attacking  the  periosteum.  Osteochondritis,  a  purely  syphilitic 
affection,  is  an  inflammatory  process  occurring  at  the  juncture  of 
the  epiphysis  with  the  diaphysis,  checking  the  normal  growth  of 
the  bones,  and  thus  producing  deformity.  Periosteitis  is  more 
likely  to  occur  after  the  child  has  begun  to  walk.  Syphilitic 
dactylitis  is  often  seen  in  young  children,  the  phalanges  and  the 
metacarpal  and  metatarsal  bones  being  enlarged  to  several  times 
their  natural  size.  These  may  break  down  and  form  abscesses. 
Craniotabes,  a  thinning  of  areas  of  the  cranial  bones,  is  often 
present,  the  product  rather  of  malnutrition,  whether  due  to  syph- 
ilis or  rickets  ;  it  especially  affects  the  occipital  bone,  since  that 
one  is  more  commonly  pressed  upon  in  normal  decubitus.  In 
proportion  to  the  severity  of  the  syphilitic  poison  is  nutrition 
disturbed  ;  in  all  cases  it  is  much  impaired.  In  the  infant  the 
typical  appearance  is  that  of  a  weazened,  pallid  old  man.  Such 
cases  are  likely  to  die.  Oftentimes  nutritional  failure  is  more 
gradual,  due  to  specific  disturbance  in  the  organs  of  digestion  or 
mere  cachectic  feebleness.  The  blood  always  suffers  more  or 
less  anemia  ;  being  deficient  in  red  corpuscles,  there  is  also  a 
marked  leukocytosis.  This  anemia  is  of  the  utmost  gravity  and 
significance,  and  may  alone,  and  directly,  cause  death.  Two 
other  diseases  are  mentioned,  common  to  childhood,  in  which 
similar  lesions  of  the  blood  appear,  and  these  are  splenic  anemia 
and  severe  forms  of  rachitis.  In  hereditary  syphilis  and  in 
rachitis  as  well  the  deciduous  teeth  are  tardy,  appearing  in  the 
tenth  or  twelfth  month,  or  later ;  they  are  usually  poorly  devel- 
46 


722  THE    SPECIFIC    INFECTIOUS    DISEASES. 

oped  and  decay  early.  There  is  slight  involvement  of  the  ner- 
vous system  in  infantile  syphilis,  the  nerve  centers  escaping  rather 
remarkably.  Apparent  paralyses,  often  accompanied  by  tender- 
ness of  the  joints,  are  occasionally  seen,  which  are  more  likely  to 
be  due  to  myopathic  changes  ;  from  whatever  cause  they  arise, 
they  readily  succumb  to  specific  treatment,  and  almost  never 
persist.  This  syphilitic  false  palsy  is  an  acute  epiphysitis,  and 
may  be  one  of  the  symptoms  or  the  first  one  of  the  disease.  The 
nails  are  subject  to  two  kinds  of  syphilitic  disturbance — ulcerative, 
from  a  pustule  appearing  on  the  margin  of  the  nail,  which  may 
destroy  the  matrix,  and  nutritive,  coming  on  more  slowly  and 
involving  the  phalanx.  A  general  irritability  is  sometimes  ob- 
served, but  does  not  differ  from  that  of  rickets. 

Diagnosis. — The  diagnosis  of  syphilis  is  not  so  difficult  where 
the  lesions  are  well  marked  and  characteristic,  or  if  there  is  a 
reasonably  honest  or  clear  history  to  be  obtained,  or  if  there  is 
an  opportunity  to  study  the  case  with  sufficient  deliberation. 
Marks  of  the  disease  upon  the  parents  are  rarely  obtained.  A 
history  of  causeless  abortion  in  the  mother  is  suggestive,  but 
requires  thorough  sifting.  This  is  said  to  occur  usually  at  or 
about  the  sixth  month  of  gestation.  The  appearance  of  the 
child  before  the  disease  shows  itself  clearly  may  tell  little,  but 
the  most  characteristic  features  are  those  of  impaired  nutrition, 
generally  without  digestive  disturbance,  and  a  loss  in  the  normal 
appearance  of  the  skin,  its  normal  freshness,  acquiring  a  shriv- 
eled look,  with  pallor  and  yellowness,  like  coffee  mixed  with 
milk.  This  is  especially  seen  in  the  face,  though  it  extends  to 
the  rest  of  the  body.  A  persistent  coryza,  however  slight, 
should  be  viewed  with  suspicion.  Mucous  patches  can  gener- 
ally be  found,  commonly  about  the  anus,  scrotum,  umbilicus,  in 
the  axilla,  mouth,  and  ears  ;  but  in  children  these  may  appear 
over  almost  any  part  of  the  surface.  The  mucous  patches  are 
liable  to  become  the  seat  of  an  ulcerative  process,  especially  the 
mouth  and  throat. 

The  following  points  of  distinction  between  syphilitic  and 
scrofulous  lesions  of  the  skin  have  been  given  by  Dr.  P.  A. 
Morrow  : 

"  I.  Syphilitic  lesions  are  general  in  their  distribution  :  they 
may  occur  upon  any  region  of  the  body.  Scrofulous  lesions  are 
more  limited  in  their  localization  :  they  have  a  special  predilec- 
tion for  the  neck  or  regions  rich  in  lymphatic  glands. 

"  2.  Syphilitic  lesions  are  ambulatory  and  changing  ;  they 
disappear  and  reappear  elsewhere.  Scrofulous  lesions  are  fixed 
and  permanent. 


SYPHILIS.  723 

"  3.  The  color  of  syphilitic  lesions  is  reddish-brown,  or  '  lean- 
ham  '  tint.  The  color  of  scrofulous  lesions  is  brighter  and  more 
violaceous  in  hue. 

"  4.  Syphilis  is  distinct  from  scrofula  in  its  objective  appear- 
ance and  mode  of  evolution.  In  the  initial  stage  the  syphilitic 
neoplasms  are  firm  and  hard ;  the  scrofulous  infiltrations  are 
softer  and  more  compressible.  In  the  ulcerative  stages  the  dif- 
ferences are  more  pronounced  :  the  ulcers  of  syphilis  are  cleaner 
cut,  regular  in  contour,  with  perpendicular,  firmly  infiltrated 
border  encircled  by  a  pigmented  areola.  Scrofulous  ulcers  are 
irregular,  with  soft,  undermined  borders ;  they  are  painless, 
bleed  easily,  and  show  slight  tendency  to  spread. 

"5.  The  crusts  of  syphilis  are  bulkier,  thicker,  with  a  tendency 
to  accumulate  in  layers,  and  darker  in  color  ;  the  cicatrices  are 
smooth  and  remain  long  surrounded  by  a  pigmented  areola. 
The  crusts  of  scrofula  are  softer,  more  adherent ;  the  cicatrices 
are  elevated,  irregular,  bridled  ;  they  retain  their  violaceous  color 
for  a  long  time. 

"  6.  The  course  of  a  syphilitic  ulcer,  though  sluggish  and 
chronic,  is  much  more  rapid  than  that  of  scrofula. 

"  7.  Absence  of  pain  and  local  reaction  characterize  both 
syphilitic  and  scrofulous  ulcers ;  they  are  essentially  lesions 
without  sensory  symptoms." 

In  connection  with  the  bony  lesions  it  is  important  to  diag- 
nose between  syphilis  and  tubercular  and  rachitic  affections. 
The  following  points  in  diagnosis  between  syphilis  and  tubercu- 
losis of  the  bones  are  given  by  Dr.  Morrow : 

"i.  Syphilis  exhibits  a  marked  predilection  for  the  long 
bones  ;  its  habitual  localization  is  in  the  diaphysis,  and  almost 
always  at  its  terminal  extremity.  Tuberculosis  is  almost  exclu- 
sively situated  in  the  epiphysis,  rarely  affecting  the  shaft. 

"  2.  In  syphilis  there  is  a  marked  enlargement  of  the  bone  by 
more  or  less  voluminous  osseous  tumors  or  hyperostoses,  with 
little  or  no  involvement  of  the  soft  parts  ;  and  in  tuberculosis  the 
tumefaction  is  due  less  to  increase  in  the  size  of  the  bone  than  to 
edematous  infiltration  of  the  soft  structures. 

"3.  In  syphilis  there  is  little  tendency  to  suppuration  and  necro- 
sis ;  in  tuberculosis  the  pyogenic  tendency  is  marked. 

"4.  In  syphilis  osteocopic  pains  with  tendency  to  nocturnal 
exacerbation  are  pronounced  features  ;  in  tuberculosis  the  pain  is 
dull  and  heavy,  not  aggravated  at  night ;  sometimes  there  is 
entire  absence  of  acute  painful  symptoms. 

"  5.  The  osseous  lesions  of  syphilis  rarely  react  upon  the  gen- 
eral system,  while  those  of  tuberculosis  often  determine  a  marked 


724  THE    SPECIFIC    INFECTIOUS    DISEASES. 

impairment  of  the  general  health,  grave  complications,  hectic 
fever,  cachexia,  etc." 

In  syphilitic  dactylitis  there  is  little  involvement  of  the  soft 
parts,  the  swelling  being  caused  by  the  enlargement  in  the  size 
of  the  bone.  In  tubercular  dactylitis  the  swelling  is  due  more  to 
an  edematous  infiltrated  condition  of  the  soft  tissues  than  to 
enlargement  of  the  bone.  In  the  latter  cases  breaking-down  of 
the  tissues  and  ulceration  are  more  apt  to  ensue. 

The  diagnosis  between  syphilis  and  rachitic  bone-lesions  may 
become  of  great  importance.  Epiphyseal  swellings  occurring 
under  six  months  are  apt  to  be  syphilitic.  In  syphilis  the 
epiphyseal  swelling  may  be  unilateral,  but  it  is  always  symmetric 
in  rachitis.  In  doubtful  cases  the  swelling  must  be  subjected  to 
specific  treatment.  It  is  well  to  remember,  however,  that  rickets 
and  syphilis  may  coexist  in  the  same  case.  There  is  almost 
invariably  enlargement  at  the  costochondral  articulations  in  all 
cases  of  rickets,  which  is  absent  in  syphilis. 

Prognosis. — Above  one-third  of  fetuses  affected  with  syphilis 
die  before  birth,  and  about  the  same  proportion  of  those  born 
alive  perish  inside  the  first  six  months.  The  earlier  the  symp- 
toms appear  after  birth,  the  severer  will  the  type  of  the  disease 
be  and  the  worse  is  the  prognosis.  If  the  digestion  remains  good 
and  the  food  supply  is  wholesome,  as  in  those  provided  with 
good  breast  milk,  the  infant  may  grow  up  and  thrive.  The  better 
the  circumstances  of  hygiene  and  environment,  the  better  the 
chances  for  full  recovery.  A  severe  coryza  interfering  with 
blood  aeration  exerts  a  very  destructive  effect  and  demands  care- 
ful treatment. 

Late  Manifestations.  —  Children  with  congenital  syphilis 
sometimes  fail  to  give  evidence  of  the  infection,  and  the  ordinary 
symptoms  as  seen  in  infancy  escape  attention.  Later,  however, 
characteristic  lesions  appear,  or  the  disorders  become  manifest  in 
certain  developmental  defects  involving  the  teeth,  the  bones,  the 
genitalia,  and,  indeed,  are  widely  extended,  but  are  not  always 
or  all  to  be  unreservedly  ascribed  to  syphilis.  In  those  instances, 
too,  where  the  disease  has  been  recognized  and  placed  under 
proper  treatment  and  the  symptoms  have  disappeared,  the  little 
one  fails  to  develop  like  other  children.  Growth  is  slow  and 
inadequate,  and  there  are  facial  and  cranial  characteristics  which 
often  render  the  disease  recognizable  at  a  glance.  A  young  man 
or  woman  may  be  neither  bigger  nor  look  older  than  a  boy  or 
girl  of  ten  or  twelve.  The  organs  of  generation  particularly 
suffer,  but  the  other  organs  are  small  and  inefficient,  and  the 
vitality  of  such  sufferers  is  low.  The  characteristic  face  is  familiar 


SYPHILIS. 

to  all  medical  students  :  the  lusterless  skin,  prominent  forehead, 
asymmetric  skull,  the  depressed  bridge  of  the  nose,  prominent 
lips  with  striated  lines  running  from  the  corners  of  the  mouth, 
the  peg-shaped  central  incisor  teeth,  notched  in  the  middle,  the 
eyelids  inflamed  at  the  edges,  spotted  or  hazed  with  cicatrices  on 
the  cornea — this  is  a  picture  familiar  in  all  clinics.  Evidences  of 
syphilis  obtrude  themselves  at  two  periods — the  time  of  second 
dentition  and  at  puberty.  The  most  graphic  feature  is  the  pecu- 
liarity described  by  Mr.  Hutchinson,  affecting  the  central  upper 
incisor  teeth,  the  significance  of  which  has,  however,  been  unduly 
exaggerated.  This  consists  in  the  loss  of  the  central  cusp,  caus- 
ing a  cupping  or  "  crescenting  "  of  the  cutting-edge,  and  also  a 
narrowing  at  this  edge,  the  base  of  the  tooth  being  wider,  and 
the  tooth  is  usually  described  as  "  peg-shaped."  The  cause  of 
this  is  said  to  be  a  defective  growth  within  the  alveolus  or  early 
infantile  stomatitis  or  alveolar  periosteitis.  There  may  also  be  a 
change  in  the  shape  of  the  palate,  which  usually  has  a  very  high 
arch,  and  ulcerative  changes  take  place  here  and  in  the  naso- 
pharynx which  result  in  shrinkage  and,  later,  deformity.  Large, 
indolent,  mucous  patches  may  occur  upon  the  gums  and  tongue, 
continuing  out  upon  the  lips  and  cheeks,  especially  at  the  corners 
of  the  mouth,  leaving  long,  striated  scars.  One  of  the  com- 
monest and  most  important  changes  is  due  to  a  periosteitis 
involving  various  long  bones,  with  thickening  upon  the  surface 
of  the  bone,  inducing  changes  in  its  form.  These  are  occasion- 
ally unilateral,  though  usually  symmetric  and  attended  with  little 
discomfort  aside  from  occasional  nocturnal  pains.  The  nasal 
bones  may  be  affected  to  the  destruction  of  the  bony  arch  of  the 
nose,  and  the  result  in  the  well-known  flattened  bridge  deformity. 
About  the  time  of  puberty  the  eye  is  liable  to  a  peculiar  form  of 
inflammation,  an  interstitial  keratitis,  producing  opacity  of  the 
cornea  without  much  disturbance  of  the  conjunctiva ;  along  with 
this  may  coexist  an  iritis  of  an  indolent  kind,  yet  lacking  the 
severe  pain  and  sensitiveness  to  light  seen  in  other  forms  of 
inflammation  of  the  iris.  The  corneal  opacity  may  obscure  this, 
as  well  as  other  deeper-seated  troubles,  as  choroiditis  and  retin- 
itis.  The  ear  is  subject  to  inflammatory  affections  from  which 
rapid  deafness  sometimes  results  in  spite  of  all  treatment.  Vis- 
ceral disturbances  occur,  and  both  the  spleen  and  the  liver  may 
become  enlarged,  alone  or  together.  A  number  of  changes  take 
place  in  the  genital  organs ;  in  younger  children  the  testicles  are 
sometimes  enlarged,  accompanied  by  hydrocele,  and  this  may 
involve  both  the  epididymis  and  the  cord  and  work  destructive 
changes.  Frequently  the  only  evidence  of  syphilis  in  early  years 


726  THE    SPECIFIC    INFECTIOUS    DISEASES. 

is  mere  arrest  and  perversion  of  development ;  the  testicles  may 
be  very  small  and  inefficient,  and  in  girls  the  mammary  organs 
fail  of  development  and  menstruation  is  liable  to  be  delayed  and 
inadequate  ;  not  seldom  such  cases  develop  epilepsy. 

Janeway  calls  attention  to  an  occasional  febrile  condition  due 
to  syphilis,  which  is  readily  confounded  with  acute  tuberculosis 
and  may  cause  death. 

•Treatment. — In  the  management  of  infantile  syphilis  the  pos- 
sibilities of  prophylaxis  are  large  if  the  parents  seek  timely  ad- 
vice. As  illustrating  what  can  be  done,  the  following  instance 
will  be  suggestive.  One  of  the  authors  had  under  treatment 
a  gentleman  with  fully  developed  syphilis  which  soon  became 
moderately  controlled.  The  mouth  presented  abundant  mucous 
patches,  slowly  healing,  and  in  flat  defiance  of  our  advice  he  mar- 
ried a  perfectly  healthy  woman.  He  followed  our  advice  in  other 
respects,  which  was  to  subject  his  wife,  as  well  as  himself,  to  sys- 
tematic treatment,  and  they  each  took  protiodid  of  mercury  in 
pill  form,  which  was  selected  for  convenience,  and  continued  for 
at  least  a  year,  at  about  which  time  a  child  was  born  which 
we  kept  under  observation  for  between  two  and  three  years, 
without  the  slightest  symptom  showing  in  mother  or  child. 
This  may  have  been  a  perfect  result,  or  developmental  defects 
might  have  shown  themselves  later.  Had  more  thorough  super- 
vision been  allowed,  perfect  prevention  might  have  resulted. 

It  must  not  be  lost  sight  of  that  the  infant  may  contract 
syphilis  de  novo  from  a  parent  or  other  source  of  infection.  In 
the  treatment  of  the  syphilitic  infant  it  is  necessary  to  use  spe- 
cific medication,  and  along  with  this  conscientious  attention  to 
nutrition.  Mercury  in  some  form  is  certainly  the  best  remedy. 
Internally  it  may  be  given  to  the  mother,  and  through  her  milk 
the  child  is  more  or  less  affected  ;  for  the  medication  of  the  child 
directly  mercury  is  best  given  by  inunction,  although  in  this  form 
it  occasionally  disagrees  ;  or  internally,  when  it  is  much  more 
likely  to  disagree  ;  or  both,  or  alternately.  This  treatment  at 
times  must  be  omitted  for  a  few  weeks,  and  iron  and  cod-liver 
oil  and  other  tonics  substituted.  The  form  for  inunction  may  be 
the  mercurial  ointment,  diluted,  if  necessary,  where  the  skin  is 
oversensitive,  or  in  its  full  strength  and  freely  where  it  is  necessary 
to  produce  a  prompt  impression  ;  and,  indeed,  it  is  important 
that  no  time  should  be  lost  in  impressing  the  system  with  the 
drug.  A  10  percent,  solution  of  the  oleate  of  mercury,  of  which 
five  drops  are  rubbed  in  three  or  four  times  a  day,  is  an  excellent 
and  cleanly  form.  Mercurial  ointment  one  part,  and  lanolin  and 
cold  cream,  of  each,  two  parts,  is  preferred  by  some.  This  should 


SYPHILIS.  727 

be  smeared  on  a  flannel  bandage  and  applied  about  the  abdomen, 
or  rubbed  in  on  the  inside  of  the  thighs  or  axillae  every  day,  using 
about  a  dram  each  time.  Before  using  the  external  applications 
it  is  important  that  the  skin  be  thoroughly  cleansed  with  soap 
and  warm  water.  Internal  medication,  on  the  whole,  is  more 
accurate  and  satisfactory,  and  various  forms  of  mercury  are 
recommended,  in  some  cases  the  iodids  also,  but  strict  care 
should  be  taken  to  keep  the  mouth  perfectly  clean  or  stomatitis 
will  result.  The  indications  and  doses  depend  to  a  great  extent 
on  the  locality  or  organ  affected — whether  the  skin,  mucous 
membrane,  lymphatic  glands,  muscles,  blood-vessels,  bones,  vis- 
cera, nervous  system,  or  the  sensory  organs,  and  upon  the  time 
at  which  the  first  symptom  was  recognized. 

Internal  medication  consists  at  first  of  the  various  mercurial 
preparations,  and  later  of  iodids  and  tonics — hematics  and  recon- 
structives.  Osier,  quoting  from  Hutchinson,  uses  the  gray 
powder, — mercury  with  chalk, — from  y1^-  to  ^  of  a  grain,  four  to 
six  times  a  day,  guarded,  if  necessary,  by  a  small  quantity  of 
Dover's  powder.  We  have  seen  these  results  of  Osier's,  know 
them  to  be  brilliant,  and  prefer  the  same  remedy.  Jacobi  recom- 
mends small  and  frequent  doses  of  calomel,  -^  to  1  of  a  grain 
three  times  a  day,  for  months  in  succession.  If  diarrhea  occurs, 
he  adds  to  each  dose  -^  to  y1^  of  a  grain  of  Dover's  powder. 
Bichlorid  of  mercury  is  advocated  by  many.  Van  Swieten's 
liquid  has  enjoyed  a  large  reputation  and  still  has  many  advo- 
cates. This  consists  of  bichlorid  of  mercury,  I  part;  water,  950 
parts  ;  rectified  spirits,  100  parts  ;  five  to  twenty  drops  in  milk 
three  times  a  day.  Baths  of  mercuric  chlorid  are  also  useful,  the 
child  being  placed  in  the  following  bath  for  fifteen  minutes  :  Mer- 
curic chlorid,  4  grains  ;  ammonium  muriate,  6  grains ;  water, 
2500  grains,  or  bichlorid  of  mercury  may  be  given  in  various  com- 
binations, from  -^-J-jj-  to  -^  of  a  grain  twice  or  thrice  daily.  A 
good  menstruum  for  this,  especially  if  intestinal  irritation  ensues, 
is  elixir  of  pepsin  or  elixir  of  bismuth.  The  mercurial  treatment 
should  be  continued  for  about  one  year  ;  longer  if  symptoms  per- 
sist. The  doses  should  be  gradually  lessened  after  six  months. 
The  treatment  is  similar  for  those  cases  of  infants  and  children 
who  have  acquired  syphilis ;  this  may  come  about  (Jacobi)  by 
the  ritual  sucking-out  of  the  circumcised  prepuce,  the  syphilitic 
nipples  of  a  mother  or  nurse,  kissing,  the  use  of  infected  instru- 
ments, and,  in  older  children,  sexual  contact.  The  acquired 
form  of  syphilis  in  infancy  and  childhood  is  apt  to  run  a  swifter 
and  more  deleterious  course  than  in  adults.  When  it  becomes 
necessary  to  check  the  ravages  of  syphilis  at  once,  mercury 


728  THE    SPECIFIC    INFECTIOUS    DISEASES. 

should  be  given  subcutaneously  ;  and  here  calomel  is  not  so 
well  borne  in  children  as  the  bichlorid  of  mercury,  one  to  two 
grains  in  an  ounce  of  distilled  water,  from  y^-  to  ^5-  of  a  grain 
twice  daily.  When  the  bones  and  glands  suffer,  it  is  well  to  add 
to  the  mercury  potassium  iodid,  two  to  five  grains  four  times  a 
day,  in  milk  or  alkaline  waters.  Children  bear  the  iodids  in  full 
doses  remarkably  well.  Under  all  circumstances  the  treatment 
must  be  persisted  in  for  many  months  after  the  disappearance  of 
the  symptoms. 

The  constitutional  disorder  may  break  out  in  one  of  many 
ways,  producing  osteitis,  a  caries  or  sclerosis  of  nerve  tissues 
affecting  the  brain  or  spinal  cord,  or  a  meningeal  exudation. 
Gibert's  syrup  consists  of  the  biniodid  of  mercury,  3  grains  ; 
potassium  iodid,  200  grains  ;  water,  3  ounces,  and  syrup  enough 
to  make  10  ounces.  Dose  for  a  child  under  three  years,  five  to 
ten  drops,  gradually  increased.  The  use  of  mercurial  fumigation 
is  advocated  by  some.  The  local  treatment  of  mucous  patches, 
excoriations,  and  especially  of  the  coryza  is  very  important.  The 
nose  should  be  kept  clean  by  a  wash,  such  as  Dobell's  solution 
or  boric  acid  in  solution  ;  so,  also,  to  the  mucous  patches,  and 
other  surface  lesions.  Mild  specific  medication  is  demanded,  such 
as  black  wash.  A  2  per  cent,  solution  of  Squibb's  oleate  of 
mercury  is  useful  applied  to  the  nose,  or  fifteen  grains  of  calomel 
to  one  ounce  of  liquid  petroleum  applied  to  the  nose  or  to  con- 
dylomata,  or  these  last  may  be  dusted  with  calomel  alone  or 
with  calomel  and  boric  acid.  Nitrate  of  silver  is  of  value  for 
indolent  lesions  and  mucous  patches  in  the  mouth  or  on  the 
genitalia.  Sluggish  symptoms,  such  as  lymphadenitis  or  pul- 
monary infiltrations,  where  there  is  reason  to  suspect  syphilis, 
will  often  yield  most  promptly  to  mercurial  treatment,  even 
though  it  is  not  certain  that  these  arise  from  syphilis  any  more 
than  from  scrofula  or  tuberculosis.  It  must  be  borne  in  mind 
that  mercury,  as  well  as  the  iodids,  has  a  tonic  effect  upon  syph- 
ilitic individuals,  and  may  be  continued  along  with  other  tonics, 
of  which  iron  is  the  chief. 

A  very  large  measure  of  attention  must  be  given  to  the  general 
health  of  children  suffering  from  syphilis,  who  are  peculiarly  fee- 
ble and  deficient  in  resistance.  This  subject  is  elaborated  in  the 
chapter  dealing  with  the  subject  of  development. 

Syphilitic  ulcers  should  be  cleansed,  then  cauterized  by  silver 
nitrate,  and  covered  with  mercurial  plaster.  For  stubborn  syph- 
ilitic affections  Ullmann  recommends  electric  mercuric  chlorid 
baths.  The  baths  should  continue  from  thirty  to  forty  minutes, 
the  electric  current  to  be  passed  through  the  bath  from  100  to 


MEASLES.  729 

200  ma.  The  addition  of  ten  grains  of  calomel  to  ten  gallons 
of  water  is  a  useful  measure.  Thyroid  extract  has  been  highly 
recommended.  Menzies  reports  four  cases  of  malignant  syphilis 
which  he  treated  by  thyro'id  extract,  no  other  remedy  being  used. 
He  noticed  an  improvement  in  all  the  cases.  From  this  he 
concludes  that  the  remedy  is  a  powerful  skin  tonic  and  a  useful 
adjuvant  to  mercury  and  potassium  iodid  in  the  treatment  of 
syphilis. 

Tiirbinger  has  called  attention  to  the  fact  that  during  mercurial 
treatment  syphilitic  patients  occasionally  develop  nephritis.  Out 
of  100  cases,  eight  had  developed  albuminuria  in  consequence  of 
the  absorption  of  mercury.  Some  believe  that  nephritis  is  due  to 
the  use  of  insoluble  preparations  of  mercury ;  the  treatment  in 
these  cases  is  to  be  discontinued,  and  during  a  long  mercurial 
course  examination  of  urine  is  not  to  be  lost  sight  of.  All  suf- 
ferers from  syphilis  require  watchfulness  for  years,  and  the  use 
of  carefully  selected  food,  tonic,  and  nutritive  stimulants. 


MEASLES. 
Synonyms. — RUBEOLA  ;   MORBILLI. 

Measles  is  an  acute  infectious  and  highly  contagious  disease, 
characterized  by  fever  and  nasobronchial  catarrh  and  by  the 
appearance  of  a  distinctive  maculopapular  eruption  on  the  face 
and  on  portions  of  the  body.  It  occurs  in  wide-spread  epidemics 
of  variable  virulence  and  extent,  recurring  every  two  years  or 
eighteen  months.  Its  spread  is  so  rapid  and  universal  that 
during  an  epidemic  few  of  the  youthful  members  of  a  community 
escape.  It  is  especially*  noteworthy  that  in  communities  which 
have  been  free  of  epidemics  for  a  long  period  the  course  of  the 
disease  is  marked  by  great  fatality ;  for  instance,  the  savages  of 
New  Hebrides  were  decimated  in  a  remarkably  short  time  by  an 
epidemic  of  measles  originating  in  a  mild  case  of  an  English 
sailor  on  board  a  trading  vessel.  In  civilized  regions,  however, 
where  the  disease  is  frequent,  the  mortality  is  relatively  small, 
practically  nothing  among  the  children  of  the  well-to-do,  whereas 
the  poorer  and  badly  nourished  children  of  lower  classes  suffer 
more  seriously.  Age  seems  to  prescribe  no  limit  to  an  attack, 
infants  occasionally  being  born  with  a  distinctly  visible  rash. 

The  febrile  incubation  may  be  as  long  as  fourteen,  even  twenty- 
two,  days,  ten  being  perhaps  the  average,  the  invasion  of  three 
to  five  days  presenting  symptoms  of  an  acute  coryza.  Measles  is 
most  highly  contagious,  and  it  is  said  the  disease  may  be  "  taken  " 


73O  THE    SPECIFIC    INFECTIOUS    DISEASES. 

from  another  at  any  time  after  the  moment  of  the  inception 
of  the  infection.  The  contagium,  however,  does  not  cling  to 
objects  so  tenaciously  nor  so  long  as  does  that  of  scarlatina ; 
indeed,  after  desquamation  and  possibly  before  the  end  of  it  the 
virulence  ceases. 

Causes. — Measles  is  due  to  a  specific  micro-organism  in  all 
probability,  but  it  has  not  yet  been  isolated.  Whatever  the  con- 
tagium is,  it  is  most  active  and  more  readily  attacks  those  unpro- 
tected by  previous  infection  than  the  poison  of  scarlatina,  but  is 
not  so  tenacious  nor  so  long  lived. 

The  medium  of  contagium  is  presumably  the  nasal  and  bron- 
chial discharges,  the  breath,  and  the  tears.  It  is  communicable 
by  mediate  contagium  and  by  the  air. 

Though  a  disease  distinctly  of  childhood,  yet  it  often  attacks 
adults  and  produces  grave  conditions  and  complications,  even 
when  the  individual  has  already  had  or  is  supposed  to  have  had 
the  disease.  Repeated  attacks  of  measles  do  occur,  but  this 
is  doubted  by  competent  observers.  Many  other  conditions 
strongly  resemble  measles,  notably  the  rashes  of  influenza  and 
rubella.  Children  at  the  breast  seldom  contract  the  disease,  or 
if  so,  it  affects  them  very  mildly. 

Symptoms.* — The  first  manifestations  of  the  attack  are  a 
marked  coryza  and  a  hard,  dry,  and  sometimes  croupy  cough. 
This  cough  may  exist  for  a  week  or  more  before  other  symptoms 
show.  A  whole  day  or  more  before  the  appearance  of  the 
eruption  the  fauces  may  be  seen  to  be  greatly  reddened  and 
injected  and  covered  with  a  distinct  rash.  This  papular  eruption 
of  the  fauces  is  observed  in  many  other  infections.  Koplik  draws 
attention  to  certain  bluish-white  "pearly"  spots  situated  on  a  red 
base,  seen  on  the  mucous  membrane  of  the  lips  and  cheeks,  about 
on  a  line  with  the  teeth.  These  are  observed  as  early  as  seventy- 
two  hours  before  the  appearance  of  the  eruption,  f  The  tongue 


*  An  early  sign  of  measles  is  recorded  by  Muenier  ("Jour,  de  Med.,"  Jan.  25, 
1898),  which  may  at  times  prove  to  be  of  practical  value,  viz.  —  a  loss  of  weight  before 
any  morbid  symptoms  occur  ;  it  is  noticeable  on  the  third  day  of  incubation  and 
becomes  more  marked  until  the  pyrexia  and  coryza  appear ;  hence  it  is  a  sign  of  the 
precontagious  stage,  and  is  independent  of  the  age  of  the  patient  or  the  severity  of  the 
attack.  This  might  lead  to  early  isolation  and  check  the  spread  of  the  malady. 

f  To  quote  the  words  of  Henry  Koplik  :  "  This  sign  is  only  of  value  as  it  appears 
on  the  buccal  mucous  membrane  (the  inner  surface  of  the  cheeks  and  lips).  Any 
signs,  spots,  or  appearances  on  the  hard  and  soft  palate,  the  pillars  of  the  fauces,  the 
conjunctiva,  are  of  no  value  and  rather  misleading,  for  signs  and  spots  exactly  similar 
to  those  described  on  the  hard  and  soft  palate  and  pillars  of  the  fauces  appear  not  only 
in  measles,  but  also  in  Rotheln,  scarlatina,  and  grip,  and  simple  sore  throat.  The 
buccal  spots,  as  described  by  me,  appear  only  in  measles,  and  in  none  of  the  exan- 
themata, and  to  my  positive  knowledge  in  no  other  known  disease  of  the  mouth  or 


MEASLES.  731 

is  coated  a  dusky  "  raspberry  "  red,  and  though  supposed  to  be 
distinctive,  this  can  not  be  relied  on.  Accompanying  the  coryza 
are  great  drowsiness,  headache,  redness  and  watering  of  the  eyes, 
sharp  injection  of  the  conjunctiva,  and  usually  a  cough.  The 
throat  is  often  sore,  with  moderate  congestion  of  the  tonsils, 
fauces,  and  larynx.  The  temperature  rises  in  the  evening  and 
falls  in  the  morning.  After  about  four  days  of  these  prodromal 
symptoms  the  characteristic  eruption  becomes  manifested.  It 
occurs  first  back  of  the  ears,  at  the  roots  of  the  hair,  but  rapidly 
spreads  over  the  face  and  neck,  which  is  the  principal  seat  of  the 
eruption.  It  is  usually  discrete,  but  may  become  confluent  in 
severe  cases.  A  bran-like  desquamation  follows.  The  rash  is 
so  characteristic  that  in  conjunction  with  the  coryza,  cough,  and 
injection  of  the  cornea  a  diagnosis  of  measles  should  not  be  diffi- 
cult, although  error  is  permissible  in  view  of  the  variations  which 
always  occur  in  the  eruptive  and  general  symptoms  of  a  specific 
fever.  The  erythema  consists  of  groups  of  dusky  red,  "  crimson  " 
papules  surrounded  by  discs  of  a  brighter  red,  which  offer  strong 
contrast  to  the  intervening  spaces  of  normal  skin.  The  papules 
are  hard,  though  not  so  "shot-like"  as  to  become  confused  in 
ordinary  cases  with  the  papule  of  variola.  Frequently  the  pap- 
ular areas  combine  to  form  a  crescent,  and  this  crescentic  appear- 
ance of  the  group  offers  a  differential  point  between  the  rash  of 
measles  and  scarlatina.  Moreover,  the  papule  of  scarlatina  is 
brighter  red,  smaller,  petechial,  and  is  not  often  raised  above  the 
surface.  In  some  serious  cases  the  rash  becomes  hemorrhagic, — 
"  black  measles," — an  evil  sign,  indicating  that  hemorrhages  may 
occur  in  the  vital  tissues.  The  maximum  temperature  is  usually 
coincident  with  the  greatest  profusion  of  the  rash.  During  the 
stage  of  eruption  the  temperature  gradually  falls  to  normal.  If 
after  the  fourth  or  fifth  day  from  the  beginning  of  the  eruption 
the  pyrexia  still  persists,  some  complication,  most  commonly 
bronchopneumonia,  should  be  suspected. 

Like  all  the  other  exanthemata,  measles  is  apt  to  vary  in 
respect  both  to  the  virulence  and  character  of  its  general  mani- 
festations. The  typical  case  is  marked  by  a  higher  or  lower  degree 
of  pyrexia,  by  its  own  peculiar  eruption,  and  by  a  catarrhal  affec- 
tion of  the  respiratory  tract.  Sometimes  one  or  another  of  these 


any  constitutional  affection.  They  must  be  looked  for  in  a  very  strong  daylight. 
They  must  be  seen  in  the  discrete  state — that  is,  small,  irregular,  rose-colored  spots, 
with  a  very  minute  bluish-white  speck,  just  large  enough  to  be  visible  in  the  center 
of  the  rose  area.  Patches  or  yellowish  specks  must  be  excluded.  We  study  the 
buccal  membrane  by  everting  it  toward  the  light  with  the  finger  or  a  depressor.  We 
observe  the  inner  surface  of  the  lips  also." 


732  THE    SPECIFIC    INFECTIOUS    DISEASES. 

symptoms  may  be  greatly  exaggerated,  or,  on  the  other  hand, 
almost  totally  absent.  In  the  milder  cases  the  eruptions  may  be 
quite  obscure  and  the  catarrhal  phenomena  slight,  while  in  the 
more  malignant  forms  the  eruption  is  darker,  more  "  angry,"  and 
the  coryza  may  develop  into  a  severe  form  of  bronchopneumonia 
which  calls  for  vigorous  treatment  on  its  own  account.  In  these 
severer  cases  the  eruption  is  apt  to  be  dilatory  in  its  progress, 
"  suppressed  "  or  "  struck  in,"  and  makes  its  appearance  at  irreg- 
ular intervals  and  on  various  parts  of  the  body.  Frequently  the 
child  has  been  manifestly  ill  for  several  days  with  bronchopneu- 
monia, and  then  the  rash  appears  on  the  buttocks,  for  instance, 
which  are  so  often  the  seat  of  various  eruptions  in  childhood, 
thus  greatly  embarrassing  a  clear  diagnosis  of  measles. 

The  more  serious  of  the  sequelae  of  measles  arise  out  of  the 
nasobronchial  catarrh  and  the  consequent  inflammation  of  the 
respiratory  passages.  As  already  stated,  the  bronchopneumonia 
is  the  most  frequent  and  indeed  the  most  dangerous  complica- 
tion ;  membranous  laryngitis  also  not  rarely  occurs.  During  the 
progress  of  these  complications  the  glands  in  the  neighborhood 
of  the  lesion,  especially  the  small  mediastinal  glands,  are  apt  to 
become  overloaded  with  the  effluvia  of  inflammation  ;  swelling 
and  induration  result,  and  there  gradually  sets  in  a  caseous  de- 
generation of  the  gland.  In  unhealthy  scrofulous  children  this 
condition  often  leads  to  cold  abscesses,  scrofulous  ulcers,  and 
many  of  the  forms  of  lung  disease,  notably  miliary  tuberculosis. 
Other  complications  are  diarrhea  and  marasmus.  The  former  is 
more  of  the  nature  of  acute  dysentery,  while  the  latter  has  been 
recorded  as  occurring  in  a  number  of  cases  of  infants  and  very 
young  children.  When  the  pyrexia  continues,  the  eruption  is 
fitful,  and  there  is  at  times  a  condition  of  ulcerative  stomatitis. 
It  may  be  said,  as  a  general  rule,  that  measles  does  not  recur 
after  the  first  attack,  but  there  is  no  doubt  that  a  relapse  may 
take  place,  and  there  may  indeed  be,  though  some  doubt  this, 
a  second  genuine  infection  after  a  period  of  one  or  more  years. 

Pathology. — Investigation  has  thus  far  thrown  but  little  light 
on  the  morbid  anatomy  of  measles.  In  the  urine  and  also  in  the 
blood-serum  and  leukocytes  micrococci  have  been  found — a  fact 
that  argues  the  need  of  further  researches  as  to  the  etiology  of 
the  disease. 

Diagnosis. — Being  of  slow  onset  and  almost  uniformly  pre- 
ceded by  symptoms  of  marked  disturbance  of  the  respiratory 
tract,  there  should  be  little  difficulty  in  differentiating  between 
measles  and  scarlatina,  the  latter  being  of  sudden  onset  and  pres- 
enting the  rash  after  the  short  period  of  twenty -four  hours.  To 


FIG.  i. 


FIG.  2. 


FIG.  3. 


FIG.  4. 


THE  PATHOGNOMOMC  SIGN  OF  MEASLES  (KOPLIK'S  SPOTS). 

FlG.  I. — The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  show- 
ing the  isolated  rose-red  spot,  with  the  minute  bluish-white  centre,  on  the  nor- 
mally colored  mucous  membrane. 

FlG.  2. — Shows  the  partially  diffuse  eruption  on  the  mucous  membrane  of  the  cheeks 
and  lips ;  patches  of  pale  pink  interspersed  among  rose-red  patches,  the  latter 
showing  numerous  pale  bluish-white  spots. 

FlG.  3. — The  appearance  of  the  buccal  or  labial  mucous  membrane  when  the  measles 
spots  completely  coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish- 
white  specks.  The  exanthema  on  the  skin  is  at  this  time  generally  fully  de- 
veloped. 

FlG.  4. — Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  mem- 
brane normal  in  hue.  Minute  yellow  points  are  surrounded  by  a  red  area.  Al- 
ways discrete. 

— ( From  ' '  Medical  News. ' ' ) 


MEASLES.  733 

differentiate  by  means  of  the  rash  is  often  rather  difficult;  in 
typical  cases  of  the  two  diseases  there  should  be  no  confusion, 
but,  as  previously  intimated,  the  form  and  nature  of  the  erythema 
in  infectious  fevers  vary  greatly.  The  spots  of  Koplik  are  a  very 
constant  and  characteristic  phenomenon. 

Complications  and  Sequelae. — Complications  are  rare  in 
patients  over  four  years  of  age.  The  commonest  is  broncho- 
pneumonia,  and  next  come  intestinal  derangements.  Mild  catar- 
rhal  laryngitis  accompanies  most  cases,  membranous  laryngitis 
not  so  rarely.  A  well-marked  pneumonia  is  found  in  nearly 
every  fatal  case.  In  certain  epidemics  pleurisy  is  a  frequent 
accompaniment.  A  true  diphtheria  may  accompany  and  is  a 
deadly  complication. 

The  heart  is  occasionally  attacked,  rarely,  it  is  said,  but  we 
have  seen  some  notable  instances  of  severe  involvement.  Measles 
may  be  complicated  by  almost  any  other  of  the  infectious  dis- 
eases, one  developing  as  the  other  subsides. 

Treatment. — Prophylaxis  is  of  far  greater  importance  and 
feasibility  than  the  laity  is  inclined  to  think.  Upon  the  first 
symptom  of  measles  the  patient  must  be  put  to  bed  and  screened 
from  the  light,  remaining  there  until  all  traces  of  the  eruption  have 
disappeared,  which  is  usually  at  the  end  of  a  week  or  ten  days, 
and  the  child  should  remain  in  the  same  room  until  the  end  of  the 
fourteenth  day,  at  least.  Another  week  should  be  spent  indoors, 
and  at  the  end  of  the  third  week,  weather  permitting,  an  outing 
may  be  cautiously  allowed.  The  temperature  of  the  sick-room 
should  be  68°  or  70°  F.,  a  little  warmer  than  for  scarlatina.  The 
bed  occupied  should  have  a  mattress  of  hair  and  be  surrounded 
by  a  screen  ;  the  coverings  should  be  light  and  only  moderately 
warm.  The  air  of  the  room  should  be  kept  constantly  fresh 
and  moist.  Drafts  can  be  avoided  by  placing  a  cheese-cloth 
screen  immediately  in  front  of  an  open  window.  While  the 
photophobia  lasts  the  room  should  be  moderately  darkened  and 
the  patient's  face  turned  away  from  the  source  of  light.  Mild 
cases  require  only  general  hygienic  measures  suitable  for  any 
febrile  disease,  with  strictly  regulated  diet  as  to  amount  and  hours 
of  feeding.  The  tendency  is  for  catarrhal  states  of  the  digestive 
organs  to  coexist  or  follow,  especially  aggravated  by  coarse 
articles  of  diet,  overfeeding,  or  the  use  of  laxatives.  The  quan- 
tity of  food  should  be  reduced  to  that  suitable  for  a  younger 
child,  and  it  may  be  fed  a  little  oftener  than  in  health,  the  food 
being  altogether  fluid.  Milk,  the  chief  item,  should  be  more 
than  ordinarily  guarded  by  alkalies  and  diluents,  to  prevent  the 
formation  of  tough  coagula.  If  gastric  irritation  sets  in,  meat- 


734  THE    SPECIFIC    INFECTIOUS    DISEASES. 

juices,  soups,  and  egg-water  should  be  substituted  in  small 
amount  and  at  shortened  intervals.  Plenty  of  water  is  to  be 
allowed,  but  not  in  too  large  drafts  at  once,  preferably  adminis- 
tered in  a  small  vessel  holding  only  an  ounce  or  two.  It  is  well 
at  the  beginning  to  secure  a  cleansing  of  the  bowels,  and  a  sim- 
ple laxative,  such  as  castor  oil  or  calomel,  may  be  used  with 
caution,  but  an  enema  is  usually  sufficient,  because  of  the  ten- 
dency to  diarrhea.  It  is  well,  also,  to  make  sure  of  skin  activ- 
ity at  the  outset  by  giving  warm  baths,  repeated  once  or  twice  a 
day,  until  the  eruption  shows  itself  abundantly  on  the  surface. 
Throughout  the  course  of  the  disease  it  is  especially  important 
to  watch  and  treat  the  catarrhal  tendency,  which  involves  the  di- 
gestive tract,  as  has  been  said,  the  respiratory  organs,  the  eyes, 
and  the  ears. 

If  the  eruption  is  distinctly  delayed  or  retrocedes,  some  com- 
plication is  to  be  feared,  and  the  skin  demands  stimulation  by  local 
applications,  such  as  heat  to  the  chest,  abdomen,  and,  above  all, 
to  the  feet  and  legs,  which  last  may  be  sufficient.  If  the  difficulty 
is  very  marked  and  inflammation  of  the  internal  organs  is  feared, 
hot  baths  or  packs  and  stimulants  are  required.  At  the  height 
of  the  eruption  the  temperature  may  rise  to  105°  F.  (40.5°  C.) 
without  aggravating  the  other  symptoms  or  signifying  anything 
serious,  unless  unduly  protracted,  when  cool  baths  should  be 
employed  at  90°  or  95°  F.  every  three  hours  and  for  half  an 
hour.  If  the  cool  bathing  seems  to  prostrate,  it  is  well  to  follow 
it  promptly  by  alcoholic  stimulants  and  external  heat.  Quinin  is 
the  safest  antipyretic,  preferably  given  by  suppository,  two  to  four 
grains  every  four  hours  for  a  child  of  ten  ;  one-fourth  of  a  grain 
for  a  child  of  two.  Few  medicines  are  required  :  For  the  fever, 
solution  of  ammonium  acetate,  or,  if  the  cough  is  troublesome, 
solution  of  potassium  citrate,  every  two  or  three  hours,  to  which 
may  be  added  syrup  of  ipecac,  five  or  ten  drops,  or  ten  or  twenty 
drops  of  paregoric,  or  both.  If  the  bronchial  catarrh  is  moderate, 
it  may  be  let  alone ;  if  severe,  or  if  bronchopneumonia  sets  in, 
the  treatment  should  be  prompt  and  efficient — carefully  applied 
counterirritation,  cold  to  the  chest,  and  stimulating  expectorants, 
as  described  elsewhere.  (See  Bronchopneumonia  and  Pleurisy.) 
Oxygen  may  be  necessary  if  the  pulse  grows  feeble  or  cyanosis 
becomes  marked,  along  with  cardiac  stimulants,  among  which 
iodid  of  potassium  must  not  be  forgotten.  For  the  eyes  a  cleans- 
ing wash,  such  as  boric  acid,  fifteen  grains  to  the  ounce,  to  which 
may  be  added,  in  extreme  photophobia,  half  a  grain  of  cocain. 
The  nares  and  pharynx,  if  markedly  catarrhal,  may  be  cleansed 
by  the  same  means,  and  subsequently  applications  made  of 


RUBELLA.  735 

glycerol  of  tannin  or  acetate  of  zinc.  Great  care  must  be  exer- 
cised during  convalescence :  the  heart  and  kidneys  must  be 
watched  and  attention  given  to  conditions  of  bronchial  and  other 
catarrhs.  Skin-cleansing  should  be  careful  and  thorough,  and 
during  the  process  of  desquamation  soothing  ointments  are  of 
value,  of  which  boric  acid  ointment  is  among  the  best.  If  the 
itching  is  great,  to  this  carbolic  acid  or  resorcin  may  be  added, 
but  carbolic  acid  is  not  altogether  safe,  especially  over  very  large 
surfaces.  Malignant  measles  requires  powerful  stimulation  and 
abundant  tonics,  especially  quinin,  digitalis,  carbonate  of  ammo- 
nium, and  mustard  baths,  along  with  brandy  or  hot  coffee. 


RUBELLA. 
Synonyms. — GERMAN  MEASLES;  ROTHELN. 

Rubella  is  a  very  mild  member  of  the  group  of  infectious  fevers, 
characterized  by  a  slight  rash  and  a  condition  of  general  malaise 
lasting  for  a  few  hours  or  two  or  three  days.  So  far  as  external 
appearances  go,  the  disease  would  seem  to  be  of  a  somewhat 
variable  character,  possessing  points  of  similarity  to  both  measles 
and  scarlet  fever.  It  is,  however,  a  separate  entity,  as  an  attack 
of  rubella  does  not  protect  either  from  measles  or  scarlet  fever, 
although  it  generally  occurs  but  once  in  a  lifetime,  nor  does  an 
attack  of  either  measles  or  scarlet  fever  confer  immunity  against 
rubella. 

Causes. — The  origin  of  rubella  is  no  doubt  bacterial,  and  there 
are  those  who  seek  to  account  for  its  frequent  resemblance  to 
measles  and  scarlatina  by  holding  that  its  cause  is  a  hybrid 
product  of  the  infectious  principles  of  these  two  more  malignant 
affections.  There  may,  indeed,  be  some  truth  in  this,  though  it 
lacks  scientific  confirmation. 

The  two  generally  recognized  forms  of  rubella — namely,  ru- 
bella morbillosa  and  rubella  scarlatinosa — are  supposed  to  be 
variations  from  the  typical  disease,  in  that  the  epidemic  is  influ- 
enced in  its  phenomena  by  the  coincident  existence  of  an  epi- 
demic of  scarlet  fever  or  of  measles,  the  rubella  taking  on  some 
of  the  characteristics  of  whichever  one  may  be  prevalent  at  the 
time.  The  disease  occurs  usually  in  epidemics,  although  sporadic 
cases  may  be  found.  It  is  of  somewhat  rare  occurrence,  does 
not  always  admit  of  unquestioned  diagnosis,  and  demands  great 
attention,  owing  to  its  unfortunate  resemblance  to  the  two  more 
serious  diseases  before  mentioned.  Rubeola  and  rubella  bear 
practically  the  same  apparent  relation  to  each  other  that  exists 


736  THE    SPECIFIC    INFECTIOUS    DISEASES. 

between  variola  and  varicella.  Much  harm  results  from  a  hasty 
dismissal  of  alarm  by  pronouncing  an  ailing  child  a  case  of 
"merely  German  measles,"  while  in  reality  the  child  is  suffering 
from  measles  or  scarlet  fever,  very  serious  diseases  and  accom- 
panied by  damaging  complications  and  sequelae.  Adults  seem  at 
times  almost  as  prone  to  attacks  of  rubella  as  are  children, 
although  the  symptoms  are  more  marked  in  the  latter.  One 
attack  engenders  a  degree  of  immunity,  but  an  evidence  to  its 
own  right  to  a  place  among  the  specific  diseases  is  shown,  as  has 
been  before  stated,  in  the  fact  that  it  grants  no  immunity  with 
respect  either  to  measles  or  scarlatina,  nor,  on  the  other  hand, 
do  these  afford  security  against  a  subsequent  attack  of  rubella 
(Griffith).  In  a  doubtful  case  strict  isolation  should  be  promptly 
enforced. 

Incubation. — The  period  of  incubation  is  variously  estimated 
at  from  one  to  three  weeks.  There  is  some  uncertainty  as  to  this, 
but  the  average  time  may  safely  be  stated  to  be  about  two  weeks. 

Symptoms. — There  are  generally  few  or  no  premonitory 
symptoms.  Occasionally,  however,  the  patient  complains  of 
slight  headache,  pain  in  the  back,  sore  throat,  and  coryza,  and 
in  some  cases  there  are  nausea  and  vomiting.  Very  frequently 
the  appearance  of  the  rash  is  the  first  symptom  noticed.  There 
is  often  swelling  of  the  cervical  glands  along  the  posterior  mar- 
gin of  the  sternomastoid  muscle.  The  rash  is  usually  a  rosier 
red  than  that  of  measles,  and  the  papules  are  ill  defined.  There 
may  be  simply  a  rosy  blush  ;  the  confluence  of  papules  and  ery- 
thema may  give  rise  to  a  suspicion  of  scarlatina,  but  the  rubella 
rash  is  not  so  clearly  punctiform  as  that  of  scarlet  fever.  The 
amount  of  fever  is  usually  small — indeed,  the  attack  is  almost 
devoid  of  any  rise  of  temperature.  In  the  majority  of  cases, 
however,  a  rise  of  from  99°  to  100°  F.  (37.2°  to  37.7°  C.)  is 
noticed,  very  rarely  to  101°  or  102°  F.  (38.3°  to  38.8°  C.). 
The  temperature  returns  to  the  normal  as  soon  as  the  rash  dis- 
appears. Some  hyperemia  of  the  conjunctiva  and  fauces  is  fre- 
quently noticed,  but  is  neither  so  common,  prolonged,  nor 
severe  as  in  measles.  The  most  distinctive  feature  is  the  affec- 
tion of  the  lymphatic  glands,  which  show  a  wide-spread,  almost 
universal  enlargement,  quite  different  from  the  more  localized 
adenopathies  of  scarlatina  or  diphtheria.  Measles  shows  rela- 
tively little  ;  in  scarlatina  the  glands  and  interglandular  tissue 
below  the  jaws  are  the  parts  more  commonly  affected. 

The  prognosis  is  most  favorable.  Quarantine  should  be  ob- 
served for  at  least  three  weeks.  Complications  are  rarely  seen 
and  in  very  severe  cases  only. 


RUBELLA. 


737 


Diagnosis. — In  epidemics  there  should  not  be  so  much  diffi- 
culty in  establishing  a  correct  diagnosis.  In  isolated  cases  mis- 
takes are  liable  to  occur,  and  rubella  may  be  mistaken  for  any  of 
the  erythematous  affections  so  common  to  childhood.  The  rash 
varies  so  widely  in  appearance  that  this  alone  can  not  be  relied 
upon  as  a  guide.  Inasmuch  as  there  is  no  positive  characteristic 
symptom  of  rubella,  there  is  often  much  confusion  in  properly 
differentiating  rubella  from  measles.  The  rash  of  measles  appears 
after  the  fourth  day  of  prodromal  symptoms,  while  in  rubella 
there  are  practically  no  prodromes.  The  presence  of  Koplik's 
spots  will  aid  in  the  decision  materially,  as  they  are  not  found  in 
rubella.  In  scarlet  fever  the  rash  is  usually  preceded  by  malaise, 
vomiting,  and  sore  throat.  The  temperature  can  always  be  taken 
as  an  important  indicator  in  determining  diagnosis.  In  rubella 
it  is  not  uncommon  for  the  patient  to  maintain  a  normal  tem- 
perature, or,  at  the  most,  to  suffer  only  a  slight  febrile  rise.  As 
an  aid  to  the  differential  diagnosis  of  the  various  infectious  dis- 
eases we  give  the  following  table,  which  has  been  taken  from  the 
admirable  text-book  of  Rotch  : 


VARIOLA. 

VARICELLA. 

SCARLET 
FEVER. 

MEASLES. 

RUBELLA. 

Incubation,  .    . 

Twelve 

days. 

Seventeen 
days. 

Four  days. 

Ten  days. 

Twenty-one 
days. 

Prodromata, 

Three  days. 

A  few  hours. 

Two  days. 

Three  days. 

A  few  hours. 

Efflorescence,  . 

Macules. 
Papules. 
Vesicles. 
Pustules. 

Vesicles. 

Erythema. 

Papules. 

Papules. 

Desquamation, 

Large  crusts. 

Small  crusts. 

Lamellar. 

Furfuraceous. 

Complications 
and  sequelae, 

Larynx. 
Lungs. 

Kidney. 
Ear. 
Heart. 

Eye. 
Lung. 
Tuberculosis. 

Treatment. — Rubella  requires  no  particular  treatment  and 
possibly  no  medication,  but  it  should  always  be  borne  in  mind 
that  an  exanthem  may  not  be  ignored,  and  care  must  be  exer- 
cised lest  some  accidental  exposure  or  state  of  exhaustion  reacts 
unfavorably  upon  the  blood  or  the  vital  organs.  We  have  seen 
many  cases  of  this  disease,  and  some  of  them  caused  much  con- 
cern. During  the  stage  of  eruption  the  bed  is  the  only  safe 
place,  or  at  least  a  uniform  atmosphere  in  one  room. .  The  diet 
should  be  exceedingly  simple,  and  large  quantities  of  water 
47 


THE   SPECIFIC    INFECTIOUS    DISEASES. 

should  be  drunk  ;  the  skin  should  be  properly  protected,  at  least 
until  desquamation  is  completed.  There  is  generally  an  uncom- 
fortable feeling  in  the  throat,  which  should  be  relieved  by  the 
antiseptic  alkaline  spray  through  the  nostrils,  followed  by  vapor- 
ized petroleum,  to  which  some  aromatic  may  be  added,  as  cam- 
phor or  menthol.  Conjunctival  irritation  is  sometimes  present, 
when  an  antiseptic  wash  may  be  needed,  as  boric  acid,  fifteen 
grains  to  one  ounce  of  distilled  water,  and  if  there  is  pain,  a 
small  amount,  as  from  one-half  to  one  grain,  of  cocain  may  be 
added.  The  bowels  should  be  kept  open. 


THE  BUBONIC  PLAGUE. 
Synonym. — MALIGNANT  POLY  ADENITIS. 

This  disease  has  received  various  names  at  different  times.  In 
1856  it  was  known  in  Tripoli  as  "typhus  with  glandular  swell- 
ing "  ;  in  the  same  year,  in  Chios,  it  was  called  "  petechial 
typhus."  In  Mesopotamia,  where  the  disease  was  prevalent  from 
1856  to  1885,  and  is  possibly  so  at  the  present  day,  it  received 
the  titles  "  adynamic  typhoid  fever  "  and  "  intermittent  fever  with 
glandular  swellings."  In  Persia,  where  the  plague  seems  to  be 
endemic  since  1856,  it  is  known  as  "  hemorrhagic  fever."  Dur- 
ing the  years  1877  to  1889  Astrakhan,  a  Russian  province,  was 
visited  by  this  disease,  which  was  described  as  "  intermittent 
fever  with  buboes,"  "  croupous  pneumonia  with  buboes,"  "  typhus 
with  glandular  swellings,  proving  fatal  with  pneumonia,"  and  a 
"peculiar  form  of  mumps." 

Plague,  or  malignant  polyadenitis,  may  be  defined  as  an  acute 
febrile  disease  of  an  intensely  fatal  nature,  characterized  by  inflam- 
mation of  the  lymphatic  glands,  marked  cerebral  and  vascular 
disturbances,  and  by  the  presence  of  a  specific  bacillus.  At  the 
present  day  the  plague  is  confined  to  Asia,  but  since  1850  it  has 
appeared  in  Europe,  Asia,  and  Africa.  The  Mediterranean  basin 
and  the  strip  of  country  running  parallel  to  that  sea  across  the 
Continent  of  Asia,  from  Turkey  to  China,  may  be  taken  as  its 
present  habitat  during  the  nineteenth  century.  It  may  prevail  in 
any  climate  and  latitude,  and  in  any  season  of  the  year.  Mod- 
erate temperatures  combined  with  dampness  favor  its  propagation. 
The  prodromata  of  the  affection  may  appear  before  an  outbreak, 
during  a  period  varying  from  a  few  weeks  to  several  years,  as 
buboes  with  fever,  and  in  a  more  or  less  epidemic  form.  This 
disease  is. readily  inoculable,  and  is  undoubtedly  contagious,  but 
the  intensity  of  its  virulence  is  greatly  modified  by  free  ventila- 


THE    BUBONIC    PLAGUE.  739 

tion  and  attention  to  hygienic  rules.  The  channels  by  which  the 
plague  may  be  acquired  are  the  alimentary  canal,  the  respiratory 
tract,  and  the  skin.  The  localities  in  which  the  disease  seems  to 
be  endemic  may  be  accounted  for  by  the  fact  that  they  have  been 
subjected  to  a  miasmatic  infection,  along  with  conditions  of  pov- 
erty, overcrowding,  and  neglect  of  the  common  hygienic  pre- 
cautions. 

Among  the  lower  animals,  the  rat  seems  most  liable  to  be 
attacked.  Rats  thus  suffering  from  or  dead  of  the  plague  may 
infect  other  animals  that  consume  them,  and,  in  addition,  rats 
are  always  affected  by  a  disease  similar  to  the  plague  at  the 
same  time  that  man  suffers. 

The  disease  is  commonly  fatal  in  children,  but  not  in  nurs- 
lings, many  of  whom  survive  their  mothers.  In  children  the 
adenitis  is  usually  most  pronounced  about  the  cervical  and  nu- 
chal region,  by  extension  from  lesions  in  and  about  the  mouth. 
In  children,  too,  there  are  cases  with  no  recognizable  buboes, 
especially  in  the  later  stage  of  an  epidemic  ;  it  is  rare  in  the 
earlier  weeks  of  its  prevalence  (Dr.  Arnold,  U.  S.  N.). 

Causes. — On  the  fourteenth  of  June,  1894,  Kitasato  and  Yer- 
sin,  working  at  the  time  of  the  epidemic  at  Hong  Kong,  demon- 
strated the  specific  bacillus  of  bubonic  plague.  It  is  described 
as  a  diplococcus  inclosed  in  a  delicate  capsule,  and  a  short 
bacillus  with  rounded  ends  and  a  clear  space  or  band  in  the 
center. 

An  interesting  fact,  demonstrated  by  some  figures  drawn  by 
Woodhead,  is  an  apparent  development  of.  the  bacillus  after 
death,  similar  to  the  development  of  the  flagella  of  the  plasmo- 
dium  malariae  some  half  an  hour  after  removal  from  the  body. 
There  has  been  nothing  definite  determined  respecting  the  influ- 
ence of  heat  or  cold,  dryness  or  moisture,  upon  the  develop- 
ment of  the  plague  ;  but  poverty,  overcrowding,  and  bad  sanita- 
tion are  potent  factors  in  its  causation. 

Notwithstanding  the  terrible  mortality  attending  the  plague, 
which  has  been  placed  as  high  as  from  90  to  95  per  cent,  of 
those  attacked,  the  disease  is  not  so  infectious  as  scarlet  fever, 
measles,  smallpox,  or  typhus.  Four  types  of  the  disease  are 
recognized:  (i)  Bubonic  or  ganglionic ;  (2)  septicemic ;  (3) 
pneumonic  ;  (4)  intestinal  (rare). 

Symptoms. — In  the  bubonic  variety  the  onset  is  usually  sud- 
den and  severe.  The  first  symptom  is  a  chill,  followed  by  a 
temperature  more  or  less  high,  and  in  some  cases  reaching  106° 
or  108°  F.  (41.1°  to  42.1°  C).  Nausea,  vomiting,,  headache, 
and  extreme  prostration  are  marked  symptoms.  A  glandular 


74O  THE   SPECIFIC    INFECTIOUS    DISEASES. 

enlargement,  usually  in  the  axilla  or  groin,  rapidly  supervenes, 
forming  a  bubo  surrounded  by  an  extreme  edema,  and  giving 
the  character  from  which  this  variety  of  the  disease  takes  its 
name. 

The  skin  is  hot  and  dry,  the  countenance  is  dusky,  the  eyes  are 
sunken,  and  the  features  are  drawn.  There  may  be  excitement  or 
apathy.  The  temperature  may  rise  suddenly  to  104°  F.  (40°  C.) 
or  more,  or  it  may  reach  its  maximum  only  after  two  or  three 
days.  In  76  per  cent,  of  cases  the  superficial  lymph-glands 
are  enlarged  and  tender.  As  a  rule,  one  group  of  glands  alone 
is  affected,  and  it  may  be  but  one  gland  in  a  group  which  shows 
signs  of  adenitis.  Ninety  per  cent,  of  the  buboes  suppurate. 
The  bowels  are  irregular,  and  the  dejecta  sometimes  contains 
blood.  The  spleen  is  always,  and  the  liver  is  usually,  enlarged. 
There  may  be  bronchial  catarrh  or  pneumonia  of  a  septic  type. 
The  renal  symptoms  vary.  During  the  first  epidemic  albumin 
is  rarely  present  in  the  urine,  while  during  a  recurrence  it  is 
found  in  95  per  cent,  of  cases.  The  nervous  symptoms  vary 
from  delirium  to  coma.  Death  may  occur  in  twenty-four  hours, 
but  the  third  or  fourth  day  is  the  fatal  period.  The  death-rate 
among  the  Chinese  and  natives  of  India  is  90  per  cent,  and 
over  ;  among  Europeans  it  is  50  per  cent.  The  symptoms  of 
plague  are  so  misleading  that  it  is  impossible  to  form  a  prog- 
nosis. 

The  diagnosis  is  most  difficult,  and  may  only  be  possible 
with  the  aid  of  the  microscope  and  bacteriologic  investigation. 

When  the  bubo  suppurates  and  breaks  down,  as  it  usually 
does,  the  disease  passes  into  the  septicemic  form.  This  form 
of  the  disease  can  also  be  produced  by  infection  through  the 
intestinal,  digestive,  or  respiratory  passages. 

The  pneumonic  form  is  the  most  fatal  of  all  the  varieties  of 
the  plague.  It  comes  on  insidiously,  the  usual  premonitory 
symptom  being  pain  in  the  side,  followed  by  difficult  and  embar- 
rassed respiration,  cough,  and  the  expectoration  of  a  bloody, 
tenacious  mucus  which,  under  the  microscope,  is  found  to  con- 
tain the  bacillus  pestis  in  great  profusion. 

Treatment. — The  most  successful  treatment  is  by  the  use  of 
the  antitoxic  serum  perfected  by  Yersin.  This,  if  used  early, 
will  forestall  the  heart  failure  so  common,  and  the  buboes  soften 
and  disappear  without  suppurating.  The  use  of  this  serum  is 
disappointing  in  the  Orient,  but  in  Oporto  it  has,  according  to 
Calmette,  reduced  the  mortality  to  almost  none. 

The  moment  plague  breaks  out  in  a  dwelling  the  patient 
should  be  removed  to  an  especially  constructed  hospital.  Per- 


GLANDULAR    FEVER.  74! 

sons  who  have  been  in  active  contact  with  the  infected  and  all  per- 
sons in"  the  dwelling  and  houses  adjacent  should  be  removed  to 
special  camps,  and  be  detained  there  for  at  least  seven  days,  and 
subject  to  medical  inspection  once  or  twice  daily.  Should  any 
of  the  "  contacts,"  as  the  exposed  persons  are  termed,  develop 
plague,  the  building  or  tent  must  be  evacuated,  disinfected,  or 
destroyed.  They  should  be  inoculated  by  Haffkine's  prophy- 
lactic, and  if  so,  they  are  exempt  from  plague  rules  for  a  period 
of  six  months. 

Should  the  bubonic  plague  visit  our  shores,  we  have  little  to 
fear  from  it.  In  bygone  epidemics,  when  it  destroyed  its  victims 
by  thousands  and  even  millions,  it  found  a  congenial  soil  in  the 
filth  and  squalor  of  the  middle  ages  or  the  barbaric  habits  of 
the  homes  of  the  far  East.  Our  greatest  safety  lies  in  the  sani- 
tation of  our  cities  ;  and  in  the  event  of  an  outbreak,  we  have  a 
second  line  of  defense  in  the  application  of  that  brilliant  dis- 
covery of  modern  science — serum  therapy. 

GLANDULAR  FEVER. 

A  disorder  called  "  glandular  fever,"  occasionally  epidemic, 
has  been  described  by  several  writers,  especially  by  E.  Pfeiffer, 
in  1889,  O.  Huebner,  and  others  since.  These  views  have  been 
criticized,  and  no  mention  is  made  of  this  disorder  in  many  re- 
cent text-books  (1900),  but,  on  the  whole,  the  testimony  is  fair 
that  a  special  disease  of  distinct  individuality  exists,  character- 
ized by  fever  and  swelling  of  the  lymph-nodes.  The  disease  is 
usually  unilateral  at  first ;  later  symmetric.  The  lymph-nodes 
are  hard  and  extremely  tender.  There  is  little  or  no  edema  of 
the  adjoining  tissues  nor  does  suppuration  occur.  Nephritis  occa- 
sionally follows,  from  which  prompt  recovery  is  the  rule.  The 
cause  is  not  known,  but  contagion  is  suspected,  not  proved.  In 
diagnosis  there  must  be  excluded  such  causes  as  the  commoner 
infections  of  mucous  surfaces  and  sympathetic  glandular  irrita- 
tions. 


CARE  AND  TREATMENT  OF   THE  HAIR  IN  ACUTE 
INFECTIOUS  DISEASES. 

If,  in  the  acute  infectious  diseases  of  childhood,  the  hair  should 
become  thinned  or  fall  out  almost  entirely,  it  will  always  be 
replaced  again  ;  therefore  on  that  score  there  need  be  no  worri- 
ment.  Frequently  the  patient  is  so  ill  or  so  delirious,  neuralgia 


742  THE   SPECIFIC    INFECTIOUS    DISEASES. 

or  headaches  are  severe,  or  perhaps  the  ice-cap  may  need  to  be 
applied  ;  it  is  then  better  to  cut  the  hair  off  completely,  "so  that 
the  patient  may  be  disturbed  or  irritated  as  little  as  possible  or 
remedies  be  properly  applied.  With  boys  and  young  girls  the 
hair  had  better  be  cut  short  early  ;  but  with  older  girls  with  a 
fine  head  of  hair  the  tresses  need  not  be  sacrificed.  The  hair 
should  be  plaited  carefully  and  the  ends  secured  safely,  so  that 
the  tresses  shall  not  become  tangled  or  matted,  and  it  need  not 
be  disturbed  for  days.  Should  the  hair  become  thickly  matted 
and  even  glued  down  with  dried  exudate,  it  need  not  even  then 
be  cut.  Soften  the  masses  with  berated  oil,  and  with  persever- 
ance and  gentle  rubbing  at  very  little  discomfort  to  the  patient 
the  tangled  mass  can  be  entirely  combed  out.  Soap  and  hot 
water  will  in  due  time  remove  the  oil. 

In  pustular  eczema,  impetigo  contagiosa,  or  pediculosis  of 
the  scalp  the  hair  should  not  be  sacrificed,  although  the  condi- 
tion presented  would  seem  to  demand  so  radical  but  hasty  a 
measure.. 

After  convalescence,  should  there  be  falling  of  the  hair  due  to 
malnutrition,  anemia,  or  seborrhea,  stimulate  the  sebaceous  glands 
and  the  hair  follicles  with  precipitated  sulphur  one  dram,  vaselin 
one  ounce  ;  or,  if  a  lotion  is  desired,  resorcin  twenty  grains,  alcohol 
or  water  one  fluidounce  ;  or  use  the  German  superfatty  soaps. 
(See  treatment  of  Seborrhea.) 


CHAPTER  XVI. 

DISEASES  OF  THE  SKIN. 


APHTHOUS   VULVITIS   OF   CHILDREN. 

Aphthous  vulvitis  is  a  disorder  peculiar  to  children,  and  which 
may  occur  in  the  course  of  such  systemic  affections  as  roseola ; 
it  has  appeared  as  an  epidemic.  It  begins  with  the  appearance 
of  twelve  or  fifteen  small  vesicles,  whitish  or  yellowish  gray,  con- 
fined to  the  neighborhood  of  the  vulva.  These  may  coalesce  in 
a  day  or  two  into  patches,  and  break  down  into  shallow  ulcers  ; 
the  surrounding  tissues  are  inflamed  and  swollen,  accompanied 
by  itching.  If  promptly  treated,  it  soon  gets  well. 

Aphthous  vulvitis  may  occur  simultaneously  with  aphthous 
stomatitis  in  the  same  individual,  and  may  be  confounded  with 
variola,  varicella,  or  localized  diphtheria,  and  it  especially  re- 
sembles herpes  of  the  vulva. 

The  treatment  consists  of  asepsis  and  the  local  use  of  some 
antiseptic  or  astringent  powder,  as  iodoform,  aristol,  boric  acid, 
or  acetanilid,  added  to  a  dusting-powder,  as  talc  or  starch. 

DERMATITIS. 

Dermatitis,  or  inflammation  of  the  skin,  may  be  due  to  the 
action  of  local  influences,  such  as  heat,  cold,  caustics,  and  other 
mechanical  and  chemic  irritants  which  directly  exert  their  effect 
on  the  skin,  and  those  which  act  indirectly,  arising  from  within 
or  taken  internally,  many  are  due  to  the  ingestion  of  certain 
drugs  and  also  to  toxins. 

Dermatitis  Traumatica. — Under  this  head  are  included  all 
those  forms  of  inflammation  of  the  skin  due  to  traumatism,  viz.  : 
contusions,  abrasions,  or  excoriations  arising  from  direct  violence 
to  the  skin — as,  for  example,  especially  in  children,  ill-fitting  gar- 
ments, shoes,  bandages,  and  other  articles  of  wearing  apparel. 
Excoriations  from  scratching,  due  to  the  presence  of  the  various 
animal  parasites,  are  important  varieties.  Other  accidental  lesions 
are  so  well  known  as  not  to  need  detailed  description. 

743 


744  DISEASES    OF    THE    SKIN. 

Treatment. — Remove  the  cause,  and,  if  necessary,  apply  sooth- 
ing lotions  or  ointments.  (See  Acute  Eczema.) 

Dermatitis  Calorica. — Extremes  of  heat  and  cold  both  pro- 
duce analogous  inflammatory  symptoms,  the  former  as  burns 
and  the  latter  as  frost-bites.  Erythema  solare,  or  sunburn,  is  a 
well-known  example  of  what  natural  heat  can  produce.  Al- 
though this  may  be  erythematous,  vesicular,  or  bullous,  it  never 
goes  on  to  complete  tissue  destruction,  as  may  happen  from  the 
ordinary  burns  or  scalds.  Cold  or  frost-bite  may  produce  death 
of  the  affected  parts  from  prolonged  interference  with  peripheral 
circulation. 

Treatment. — In  burns  of  a  mild  degree  a  saturated  solution 
of  boric  acid  or  calamin  lotion  (for  formula  see  Erythema) 
should  be  applied  frequently  on  lint  and  the  parts  be  kept  well 
moistened ;  or  boric  acid  one  dram  and  petrolatum  one  ounce 
may  be  used. 

Frost-bite. — If  seen  immediately  after  exposure,  bring  parts 
gradually  back  to  normal  temperature  by  gentle  friction  by 
rubbing  with  snow  or  cold  water.  We  have  seen  two  cases  in 
which  children  were  told  to  plunge  their  feet  while  excessively 
cold  in  warm  water  result  in  an  angioneurotic  edema. 

Treatment. — After  the  parts  are  restored  to  their 'normal  tem- 
perature, stimulation  is  called  for — applying  a  12.5  to  25  per 
cent,  ichthyol  ointment  in  petrolatum  or  strongly  carbolized  oint- 
ments. Use  warm  woolen  stockings,  avoid  the  girdle  garter, 
and  also  avoid  approaching  a  fire  too  soon,  which  causes  tingling 
and  burning  sensations.  The  fluid  preparations  of  diastase  are 
very  soothing  to  subacute  conditions. 

Dermatitis  Venenata. — This  heading  includes  all  inflamma- 
tions caused  by  numerous  external  irritants  which  act  deleteri- 
ously  on  the  skin.  The  commonest  causes  are  the  well-known 
irritants, — mustard,  turpentine,  cantharides,  mezereon,  arnica, — 
anilin  and  corallin  dyes  (from  undergarments  and  stockings), 
mercurial  ointments,  poisonous  insects  and  fish — Portuguese  men- 
of-war,  etc.  But  the  most  common  causes  are  the  rhus  plants 
— poison-ivy  (or  poison  oak)  and  poison  sumac  (or  poison  dog- 
wood). The  susceptibility  to  this  poison  in  individuals  varies  to 
a  great  extent ;  some  can  handle  the  plants  with  impunity,  while 
in  other  cases  mere  proximity  is  sufficient  to  cause  cutaneous 
disturbance  (toxicodendric  acid,  Maisch).  The  lesions  produced 
on  the  skin  are  erythema,  wheals,  papules,  vesicles,  pustules,  or 
bullae,  with  or  without  edema  and  swelling.  The  effect  produced 
depends  on  the  susceptibility  of  the  individual,  the  virulence  of 
the  poison,  and  the  length  of  exposure,  or  a  combination  of  any 


DERMATITIS.  745 

or  all.  The  symptoms  of  poisoning  by  rhus  toxicodendron 
(poison-ivy  or  oak  or  poison  sumac  or  dogwood)  appear  soon 
after  exposure.  As  a  rule,  the  poison  acts  quickly,  a  few  hours 
often  being  sufficient  to  provoke  an  attack  ;  in  other  cases  several 
days  are  required.  The  vesicles  vary  in  size  from  that  of  a  pinpoint 
to  that  of  a  split  pea,  and  are  seated  on  inflamed  and  usually  in- 
flammatory bases.  These  vesicles  are  frequently  angular  (eczema 
vesicles  are  always  round),  and  at  times  are  arranged  in  streaks 
or  lines.  They  may  coalesce  into  blebs  and  become  seropurulent 
or  pustular.  Marked  itching  and  burning  are,  as  a  rule,  present. 
The  hands,  face,  and  forearms  (in  the  male  the  genitalia  also)  are 
the  favorite  parts  involved.  The  disease  runs  an  acute  course  ; 
the  vesicles  burst  spontaneously  or  are  broken,  the  contents 
drying  into  yellow  crusts.  The  process  may  continue  for  from 
one  to  six  weeks  and  terminate  in  complete  recovery  ;  or,  in 
those  inclined  to  eczema,  it  may,  however,  result  in  a  persistent 
form  of  that  disease. 

Treatment. — Remove  the  cause  and  apply  soothing  lotions  and 
ointments,  as  in  acute  eczema.  For  rhus  toxicodendron  poison- 
ing Duhring  recommends  the  extract  of  grindelia  robusta,  one 
fluidram  to  four  to  six  fluidounces  in  water.  We  have  used  a 
saturated  solution  of  boric  acid  with  good  effect ;  also  calamin 
lotion  and  black  wash,  followed  by  oxid  of  zinc  ointment. 

Dermatitis  Medicamentosa. — As  a  rule,  the  ingestion  of 
drugs,  especially  in  children,  does  not  produce  an  eruption,  yet 
the  number  of  drugs  which  may  produce  disturbances  of  the  skin 
is  considerable  and  may  cause  difficulties  in  diagnosis.  It  is 
usually  due  to  an  idiosyncrasy,  to  some  defect  in  the  elimination, 
or  to  a  poisonous  dose,  or,  perhaps,  a  combination  of  these  con- 
ditions. Acetanilid  produces  a  bluish  tint  of  fingers  and  lips — a 
cyanosis. 

Antipyrin  (phenazone)  causes  an  erythematous  rash,  morbilli- 
form  in  character,  and  desquamation  may  follow.  The  eruption 
becomes  confluent  in  patches.  An  important  practical  point  here 
is,  in  a  febrile  case  of  a  child,  cause  not  known,  not  to  give  anti- 
pyrin  as  a  febrifuge,  as  the  drug  may  bring  out  an  erythematous 
rash  and  mask  the  true  nature  of  the  disease.  The  rash  of  arsenic 
is  erythematous  or  urticarial,  or  herpes  zoster  may  be  produced 
at  times  (J.  Hutchinson).  Atropin  (belladonna)  produces  a  diffuse 
erythematous  blush,  scarlatiniform,  especially  in  children.  The 
differential  diagnosis  is  fortunately  readily  established  by  the  dry- 
ness  of  the  throat,  dilated  pupils,  and  the  absence  of  fever  and 
of  desquamation. 

BROMIDS. — The  great  majority  of  eruptions  met  with  in  con- 


746  DISEASES    OF    THE    SKIN. 

nection  with  this  group  of  drugs  are  pustular.  They  are  usually 
acneform,  and  occur  in  the  favorite  sites  of  acne,  viz. — the  face, 
chest,  back,  and  scalp.  Sometimes  they  are  furunculoid  or 
bullous.  In  infants  the  eruption  is  liable  to  become  confluent 
(Crocker).  The  lesions  often  continue  to  come  out  even  after  the 
use  of  the  drug  has  been  suspended. 

Treatment. — Discontinue  the  drug  and  give  arsenic  internally. 
In  cases  of  epilepsy,  when  bromids  are  necessary,  the  addition 
of  arsenic  will  often  prevent  the  acneform  cutaneous  lesions. 

CHLORAL  HYDRATE. — Skin-lesions  resulting  from  chloral  are 
mostly  eiythematous,  dusky  red  papules  or  a  general  scarlatini- 
form  rash,  followed  by  desquamation.  "  The  oral  and  pharyn- 
geal  mucous  membrane  is  also  red,  increasing  the  liability  of  its 
being  mistaken  for  scarlatina,  as  a  rise  of  two  or  three  degrees 
of  temperature  is  not  uncommon  "  (Crocker). 

IODID  eruptions  are  mostly  pustular,  acneform,  appearing  on 
the  neck,  shoulders,  arms,  and  chest.  They  are  also  bullous  at 
times,  and  may  be  erythematous,  papular,  hemorrhagic,  or 
purpuric. 

OPIUM  eruptions  are  erythematous,  scarlatiniform,  often  accom- 
panied by  pruritus,  especially  of  the  nose,  but  this  may  be 
general. 

QUININ  eruptions  are  usually  erythematous  and  may  be 
urticarial. 

TURPENTINE  eruptions  are  erythematous. 

ECTHYMA. 

Ecthyma  is  an  inoculable  and  an  autoinoculable  disease  of  the 
skin,  characterized  by  the  formation  of  one  or  more  rounded 
pustules  resting  upon  an  inflamed  base  and  having  a  tendency  to 
spread  eccentrically,  with  the  formation  of  a  brownish  crust.  It 
closely  resembles  pustular  eczema,  but  in  this  country  is  differ- 
entiated from  it  clinically.  It  begins  as  a  red  point,  on  the 
second  day  appearing  as  a  small  papule  or  pustule  in  the  center 
of  an  inflamed  area ;  on  the  third  day  it  becomes  accuminated 
in  the  center ;  it  then  increases  in  size  to  the  fifth  or  eighth  day, 
when  it  becomes  a  large,  flattened  pustule  ;  by  the  ninth  or 
eleventh  day  the  central  crust  is  formed,  surrounded  by  a  whitish 
circle,  formed  by  the  elevation  of  the  epidermis  by  pus  ;  thence 
it  begins  to  heal,  and  by  the  fifteenth  or  twentieth  day  the  lesion 
begins  to  disappear,  leaving  a  more  or  less  reddish-brown  pig- 
mented  stain.  Superficial  cicatrices  may  result  if  the  destructive 
ulceration  has  been  deep  enough.  Ecthyma  usually  attacks  the 


ECZEMA.  747 

lower  limbs,  although  appearing  elsewhere.  There  are  slight 
itching  and  burning.  Furuncle  differs  from  ecthyma  by  its  more 
vivid  red  color  and  deeper  infiltration.  It  may  be  transferred 
from  one  part  to  another  by  scratching,  whereupon  new  lesions 
arise  by  inoculation,  and  it  usually  appears  in  debilitated  people. 
The  treatment  is  systemic  and  tonic — extra  diet,  pepsin, 
cod-liver  oil,  and  iron  in  the  form  of  Basham's  mixture.  Locally, 
antiseptics  and  parasiticides  are  necessary.  The  crust  should 
be  removed  by  a  starch  poultice  containing  boric  acid,  and  the 
lesions  washed  with  sublimate  solution  and  dressed  with  an 
ointment  of  boric  acid  I  dram,  calomel  1 5  grains  to  the  ounce 
of  oxid  of  zinc  ointment. 


ECZEMA. 

Eczema  is  the  most  common  disease  of  the  skin  in  this 
country,  constituting  from  one-fourth  to  one-third  of  all  cases. 
It  is  of  almost  infinite  variety  and  distribution,  and  closely 
simulates  a  large  number  of  other  skin  disorders.  It  is  usually 
disfiguring  and  painful  through  the  intensity  of  the  itching  and 
burning  which  accompany  its  progress.  Eczema  is  an  inflam- 
matory, acute,  or  chronic  disease  of  the  skin,  characterized  at  its 
commencement  by  eiythema,  papules,  vesicles,  or  pustules,  or  a 
combination  of  these  lesions,  accompanied  by  more  or  less  infil- 
tration and  itching,  ending  either  in  discharge,  with  a  formation 
of  crusts,  or  in  desquamation.  It  is  also  described  as  a  catarrh 
of  the  skin,  affecting  as  it  does  the  mucous  layer.  As  encoun- 
tered in  children  it  has  much  the  same  features  as  in  adults,  but 
occupies  certain  situations  more  frequently  in  a  child,  as  the  scalp 
and  face.  It  is  also  of  a  more  acute,  inflammatory  type,  and  there 
is  greater  evidence  of  glandular  enlargement,  abscesses,  and  boils, 
especially  in  ill-nourished  children  or  those  of  depraved  vitality. 
The  enlarged  glands  rarely  suppurate.  In  former  times  all 
these  were  regarded  as  forms  of  sympathetic  adenitis  ;  it  is,  how- 
ever, not  an  evidence  of  constitutional  disease,  but  merely  a  suffi- 
cient irritation  for  which  pediculosis  capitis  is  an  ample  cause. 
Eczema  in  children  may  be  acute,  arising  de  novo  from  various 
causes,  both  general  and  local,  and  is  then  quite  manageable. 
It  is  much  more  commonly  met  with  as  a  subacute  disorder  fol- 
lowing in  the  wake  of  a  host  of  causes,  the  diverse  forms  of 
dermatitis  and  various  specific  diseases  of  the  skin  and  the 
exanthemata.  Eczema  may  occur  as  a  localized  patch  upon  the 
cheeks  or  scalp  or  under  the  chin,  or  generalized,  scattered  over 
the  body  and  limbs  in  infiltrated  patches  of  various  sizes,  appear- 


74-8  DISEASES    OF    THE    SKIN. 

ing  scaly,  in  aggregations  of  papules,  or  in  weeping  and  raw 
surfaces. 

It  may,  at  times,  be  inveterately  chronic,  defying  the  wisdom 
of  the  elect,  and  obdurately  resisting  every  effort  at  relief,  until 
the  patience  of  the  medical  adviser  is  exhausted  along  with  his 
wisdom,  and  to  shield  himself  he  may  claim  that  to  cure  it  at  this 
stage  would  be  "to  drive  it  in  and  imperil  life."  Again,  a  criti- 
cal epoch,  such  as  the  eruption  of  certain  teeth,  the  period  of 
puberty,  a  change  in  climate  or  in  the  weather,  the  rotation  of  the 
seasons,  or,  what  is  often  very  efficacious,  a  complete  alteration 
in  the  environment  and  feeding,  brings  relief. 

The  form  of  the  eruption  may  be  the  typical  one  of  erythema, 
papules,  vesicles,  or  pustules,  all  of  which  may  not  be  present  at 
the  same  time,  one  form  merging  into  another ;  but  usually  one 
will  predominate.  Any  one  of  these  may  develop  into  eczema 
rubrum,  which  exhibits  a  red,  raw,  weeping  surface  due  to  the 
exposure  of  the  rete  mucosa,  a  shedding  of  the  upper  epithelial 
layers.  Squamous  or  scaly  eczema  may  also  follow  upon  any  of 
these  primary  forms,  appearing  in  patches  of  red,  scaly,  and 
thickened  skin.  Finally,  by  reason  of  the  duration  of  the  dis- 
order or  its  position  upon  tougher  or  tenderer  parts  of  the  skin, 
there  may  arise  a  bark-like  hardness  or  horny,  cracked,  or 
fissured  conditions.  The  most  important  symptom  by  far  is  the 
itching ;  this  is  the  real  disease,  and  passes  the  descriptive 
capacity  of  most  sufferers,  and  likewise  overwhelms  their  en- 
durance. Eczema  bears  a  close  similitude  to  catarrhs  of  the 
mucous  membrane,  both  in  its  habit  of  discharge  and  tendency 
to  relapse.  To  be  sure  it  often  happens  that  the  exudate  is 
scanty,  and  eczema  may  remain  a  dry  disease  throughout  its 
course,  but  it  is  capable  of  being  made  at  any  moment  a  wet  one 
by  sufficient  irritation  and  scratching. 

Cause. — Eczema  is  the  most  frequently  occurring  skin  disease 
in  childhood.  It  is  a  catarrhal  inflammation  of  the  skin  to  which 
the  delicate  tissues  of  childhood  are  especially  liable,  and  from 
exciting  causes  the  most  numerous.  There  is  a  predisposition  in 
some  children  to  skin  troubles,  or  rather  to  a  vulnerability  of  the 
skin,  probably  because  it  is  not  well  developed  or  because  the 
individual  has  feeble  resistance.  In  badly  nourished  children  of 
lowered  vitality  from  defective  hygiene  and  constitutional  inheri- 
tance eczema  is  most  likely  to  arise,  especially  the  pustular  form, 
and  it  is  frequently  accompanied  by  swollen  glands,  ciliary  bleph- 
aritis, and  mucopurulent  conditions  of  the  ears.  Vaccination  is  a 
common  cause  or,  rather,  an  irritative  starting-point  in  a  suscepti- 
ble child  ;  so  is  measles,  in  which  it  often  attacks  the  edges  of  the 


ECZEMA.  749 

eyelids.  The  dietetic  errors  competent  to  initiate  eczema  are  of 
large  variety  ;  too  much  food,  especially  of  a  coarse  or  improper 
kind,  is  quite  as  bad  as  too  little.  A  food  overrich  in  proteids 
seems  to  be  hurtful,  and  certainly  helps  to  produce  one  of  the 
causes,  which  is  overacidity  of  the  blood  ;  also  such  foods  as 
readily  induce  gastric  acidity,  such  as  undercooked  oatmeal,  with 
sugar  and  cream,  is  recognized  as  a  direct  cause.  Dentition  is 
blamed  unduly  for  inducing  eczema,  but  it  is  merely  one  ground 
for  susceptibility  to  irritation.  There  are  many  exciting  causes  : 
cold  and  damp  weather,  depressing  heat,  bad  soaps,  hard  bathing 
water,  and  rough  underclothing.  There  is  a  large  variety  of  or- 
ganisms capable  of  producing  eczema,  especially  when  the  secre- 
tions have  undergone  decomposition. 

Treatment. — To  be  accomplished  in  the  treatment  of  eczema 
is  a  possession  in  itself.  So  rarely  does  the  average  practitioner 
attain  this  distinction  that  it  is  well  worth  choosing  as  a  special 
subject  of  study.  This  can  not  be  acquired,  or  only  through 
infinite  labor  and  pain,  unless  the  student  has  an  opportunity,  of 
which  he  shall  avail  himself  adequately,  to  work  in  a  skin  dis- 
pensary for  a  considerable  time  under  the  tutelage  of  a  master 
of  the  art ;  such  has  been  the  authors'  privilege,  and  so  large 
and  difficult  is  the  subject,  and  so  many  failures  have  followed 
our  efforts,  that  the  wonder  is  how  any  one  could  get  along 
without  a  similar  experience.  We  have  had  very  good  success 
in  treating  eczema  in  babies  and  children  upon  this  general  out- 
line :  First,  to  regulate  the  diet,  which  in  most  instances  requires 
thorough  revision ;  next,  to  use  some  laxative  and  alkaline 
medicine  which  shall  relieve  both  the  bowel  of  offending  matters 
and  expedite  the  flow  of  urine  and  lessen  its  hyperacidity ;  then 
comes  the  enforcement  of  rather  more  rest  and  sleep  than  the 
child  has  been  accustomed  to  get ;  the  relief  from  excitement  of 
all  kinds  as  much  as  possible.  The  room  in  which  the  baby  is 
kept  should  be  of  a  southern  exposure,  defending  it  against  heat 
in  summer,  as  much  as  possible,  and  cold  in  winter,  and  damp- 
ness at  all  times.  A  common  room  or  living  room  wherein 
cooking  and  washing  takes  place,  often  simultaneously,  alternat- 
ing with  clouds  of  steam  and  burnt-up  air  from  red-hot  stoves 
and  ranges,  is  most  pernicious  to  tender  skins  and  mucous 
membranes,  producing  catarrh  of  the  respiratory  passages,  eyes, 
and  mouth,  and  also  producing  catarrhal  conditions  of  the  skin, 
of  which  eczema  is  the  chief.  Such  a  room  is  also  in  a  perpetual 
cycle  of  overheat  or  overcold.  In  children  of  the  well-to-do 
classes  this  danger  is,  of  course,  escaped,  and  among  them 
eczema  is  not  so  prevalent.  They  also  escape  another  danger 


7  SO  DISEASES    OF    THE    SKIN. 

of  the  more  ambitious  of  the  poorer  folk,  who  are  overzealous 
in  their  use  of  soap  and  water.  The  final  important  hygienic 
consideration,  then,  is  care  in  the  pursuit  of  personal  cleanli- 
ness, in  which,  among  babies,  not  so  much  soap  should  be 
employed  and  a  better  article  selected.  It  is  not  a  question  of 
cheapness,  for  good  Castile  soap  costs  no  more  than  the  ever- 
handy  laundry  soap,  which  is  found  so  efficacious  upon  pots  and 
pans  and  is  made  to  do  efficient  duty  on  the  very  dirty  child. 
Again,  whatever  soap  is  used,  be  it  good  or  bad,  it  should  be 
completely  washed  away  after  having  been  applied,  which  in 
infants  and  children  should  always  be  sparingly.  A  good  prac- 
tical rule  is  to  insist  in  the  final  use,  during  the  process  of  ablu- 
tion, of  another  cloth  and  cooler  water,  which  will  make  sure  of 
a  final  riddance  of  all  soap.  Moreover,  the  water  used  warrants 
care,  and  it  is  well  that  it  should  be  boiled  before  using. 

So  much  for  prevention  as  well  as  cure.  When  an  eczema  is 
present,  or  a  dermatitis  from  which  it  may  come,  the  first  rule  is 
to  insist  that  no  soap  whatever  shall  be  used,  and  only  lukewarm 
boiled  water  (better  still,  saturated  solution  of  boric  acid)  spar- 
ingly for  cleansing  purposes.  To  this  may  be  added,  with  great 
advantage,  a  solution  of  bran,  made  by  taking  a  hanjdful  of  bran, 
wrapped  up  in  a  loose  meshed  cloth,  dipped  in  hot  or  boiling 
water,  and  then  stirred  about  and  finally  squeezed  into  the  bath 
water.  To  this  it  is  sometimes  well  to  add  a  teaspoonful  of 
bicarbonate  of  soda  or  of  washing  ammonia  to  a  basinful,  and, . 
if  there  is  much  itching,  from  fifteen  to  twenty  drops  of  carbolic 
acid  or  essence  of  mint,  one  or  all.  The  carbolic  acid  has  a 
certain  danger  unless  cautiously  used  and  in  limited  areas. 
Lastly,  as  a  protective  as  well  as  a  cleanser,  sweet  oil ;  by  this 
is  meant  olive  oil,  when  procurable,  not  cotton-seed  oil,  to  each 
ounce  of  which  add  one  to  five  grains  of  carbolic  acid. 

For  large  areas  in  babies  a  boric  acid  ointment — boric  acid 
one  dram,  petrolatum  one  ounce — is  safer  and  better.  This,  ap- 
plied after  a  water-bath,  defends  the  skin  from  irritation  of  cloth- 
ing or  moisture  or  whatever  cause,  and  if  the  eczema  is  quite 
annoying,  used  upon  a  soft  doppel  of  cotton  will  serve  admirably 
in  lieu  of  the  water  bath.  Under  this  treatment  most  eczemas 
of  infants  will  get  well.  In  addition  to  this  may  be  used  powders, 
antiseptic  and  soothing, — powders  should  always  be  both, — or 
sometimes  an  ointment  is  needed,  first  soothing  and  later  stimu- 
lating. It  will  be  noticed — and  observant  mothers  will  volunteer 
this  information — that  eczema  of  the  exposed  parts,  as  the  face 
or  head,  is  obviously  worse  in  damp,  stormy  weather  or  when 
melting  snow  is  about,  and  grows  conspicuously  better  as  soon 


as  a  dry  air  prevails.  Children  with  susceptible  skins  will  need 
to  be  protected  by  veils  when  abroad,  and,  indeed,  should  not  be 
allowed  to  go  out  in  very  bad  weather.  The  ideal  condition  for 
an  eczematous  child  is  a  large  room  opening  to  the  south,  with 
abundant  window  light,  heated  in  such  a  way  as  not  unduly  to 
parch  the  air,  and  in  which  a  number  of  healthy,  growing  plants 
are  placed.  The  plants  aid  materially  in  regulating  the  atmos- 
pheric moisture  in  the  most  beneficent  way.  Such  a  room  needs 
very  little  artificial  heat,  especially  in  sunny  weather ;  the  chil- 
dren can  be  dressed  as  if  for  out-of-doors.  Indeed,  it  is  always 
better  for  children  able  to  play  about  alone  to  have  a  thoroughly 
ventilated  room,  like  the  one  described,  and  to  use  extra  clothing 
rather  than  artificial  heat  for  warmth.  The  disease  in  young 
infants  is  usually  acute  ;  first,  erythematous  eczema,  then  papular, 
rapidly  running  into  vesicular,  then,  as  affected  by  scratching  and 
rubbing,  there  results  the  pustular  or  the  red  weeping  eczema  ; 
accompanying  is  a  certain  degree  of  infiltration,  and  along  with 
this  a  severe  and  painful  itching,  and  the  disease  is  extended  by 
the  aggravation  induced  by  scratching  and  rubbing.  It  is  a 
matter  of  amazement  what  an  enormous  strain  from  this  infants  can 
endure  for  weeks  and  months.  In  adults  it  would  induce  a  pros- 
tration of  the  nervous  forces  most  disastrous.  But,  as  has  been 
said  by  Dr.  White,  of  Boston,  it  not  seldom  happens  that  a 
whole  household  is  exhausted  in  its  endeavors  to  relieve  the 
sufferings  of  an  infant,  who  not  only  retains  its  vigor  and  plump- 
ness, but  in  the  end  is  the  only  healthy  member  of  the  family. 
An  ancient  fallacy  prevails  still  in  remote  places,  and  be  it 
asserted  with  caution,  too,  in  high  places  in  our  midst,  that  it  is 
in  some  sense  perilous  to  apply  local  remedies,  which  may 
endanger  the  patient's  life  by  driving  the  disease  inward.  This 
is  a  rag  of  the  ancient  humoristic  theory,  used  as  a  skeptic  cloak 
to  cover  ignorance. 

Van  Harlingen  lays  down  "  two  general  principles  which 
obtain  in  regard  to  the  local  treatment  of  eczema  ;  these  are, 
first,  that  in  the  acute  form  the  treatment  can  scarcely  be  too 
soothing  ;  second,  that  in  the  chronic  form  the  treatment  can 
hardly  be  too  stimulating.  So  long  as  there  are  eczema  and 
hyperemia  there  will  be  itching  ;  so  long  as  there  is  itching  there 
will  be  scratching  ;  so  long  as  there  is  scratching  there  will  be 
no  chance  for  the  excoriated  skin  to  heal."  The  infant  or  young 
child  can  not  be  wrapped  up  in  a  cloth,  swaddled  in  fact,  in 
Ioti6ns  or  ointments,  but  these  must  be  applied  in  such  a  way  as 
to  permit  freedom  of  movement ;  therefore  one  of  the  most 
valuable  devices  is  the  close-fitting  garment  devised  by  Dr.  White, 


752  DISEASES    OF    THE    SKIN. 

made  of  linen  or  lint,  on  which  these  may  be  applied,  and  forms 
a  protective  coating  to  the  inflamed  skin.  This  consists  of  a 
mask,  fitting  the  head  and  face,  with  apertures  for  the  eyes,  nose, 
and  mouth,  and  slits  for  the  ears.  It  is,  perhaps,  best  adjusted 
by  safety-pins,  and  worn  for  twenty-four  hours,  or  changed  at 
shorter  or  longer  intervals.  It  is  wise,  also,  where  the  trunk 
and  limbs  are  affected,  to  use  a  sort  of  strait-jacket  in  addition 
to  the  mask,  and  it  is  well  that  it  should  cover  the  hands  and 
feet  also ;  the  covering  of  the  hands  defends  the  skin  from 
scratching.  This  will  immensely  shorten  the  course  of  the  dis- 
ease. Local  remedies  must  be  selected  with  strict  attention  to 
the  character  of  the  lesions  in  each  individual  case.  Acute 
eruptions  should  usually  be  treated  with  soothing  remedies.  If 
crusts  form,  they  had  best  be  removed  by  boric  acid  ointment 
(one  dram  to  one  ounce)  before  decomposition  with  its  conse- 
quent irritation  sets  in.  If  itching  is  severe  and  aggravated  by 
the  rapid  formation  of  vesicles,  these  should  be  allowed  vent ; 
when  there  is  extensive  infiltration  along  with  itching,  stimu- 
lating measures  are  required.  To  soften  down  the  crusts  a  starch 
poultice  is  of  value,  to  which  should  be  added  10  parts  of  boric 
acid  to  1000.  This  gives  great  relief,  and  should  _be  changed 
from  every  three  to  six  hours.  In  less  severe  cases  muslin  dipped 
in  bran  or  starch  water  and  covered  with  waxed  paper  will  do 
very  well. 

ACUTE  ECZEMA. 

In  the  choice  of  a  remedy  to  relieve  acute  eczema  it  is  better 
to  begin  by  making  the  application  over  a  limited  area  until  its 
effect  is  learned.  In  this  way  several  remedies  can  be  used  if  the 
affected  areas  are  extensive,  and  that  which  produces  the  best 
effect  can  then  be  chosen.  Cautious  experimentation  is  essential 
to  success.  A  powder,  mostly  of  starch,  is  best  suited  for  large 
surfaces,  to  which  may  be  added  lycopodium,  bismuth,  talc,  der- 
matol,  or  other  suitable  powder  in  experimental  patches.  Moist 
applications  are  oftentimes  soothing  and  represent  a  continued 
bath.  The  starch  poultice  is  one  of  the  most  reliable  of  the 
moist  applications,  adding  5  to  10  parts  of  boric  acid  to  1000, 
as  previously  described.  Potato  starch  is  preferred.  It  may 
be  made  by  placing  the  starch  in  a  flat  bag,  dipping  in  boil- 
ing water,  and  cooling ;  or  ordinary  washing  starch  rubbed  into 
a  smooth  paste  with  cold  water  and  spread  upon  linen  and  fastened 
with  bandages  may  be  used.  This  remedy  gives  great  relief  if 
used  carefully  and  changed  from  every  three  to  six  hours.  For 
the  ordinary  run  of  cases  a  decoction  of  bran  or  starch  water 


ECZEMA.  753 

applied  on  soft  muslin  and  covered  with  thin  impermeable  cloths 
will  suffice.  If  the  same  cloths  are  reappliecl,  they  must  be  dis- 
infected each  time  and  creases  and  folds  avoided.  If  the  patient 
becomes  chilly  from  these  wet  dressings,  a  layer  of  cotton-wool 
or  flannel  may  be  placed  over  them.  A  good  routine  plan  for 
acute  eczema  is  to  begin  by  bathing  the  part  with  diluted  black 
wash,  or  the  following  modification  of  it : 

R  .      Hydrarg.  chlor.  mite, g  ss 

Mucilago  tragacanthce,  3J 

Liq.  calcis, f  3  xj. 

Apply  on  cloths  laid  on  the  skin  for  a  few  minutes. 

Then,  with  the  finger,  gently  rub  into  the  surface,  before  it 
becomes  dry,  the  following  ointment : 

R  .  Ung.  zinci  oxidi, 
Ung.  aquae  rosae, 
Petrolat.,  aa  giv. 

Or  Lassar's  paste : 

R.     Acid,  salicyl., gr.  x 

Zinci  oxidi, 

Pulv.  amyli, .    .      aa  zij 

Petrolat.,      5  ss. 

Apply  three  times  daily  after  first  cleansing  the  surface  with  cosmolin. 

Other  washes  recommended  are  these  : 


Also  : 


R .     Liq.  plumbi  subacetat.  dil. , Oss 

Glycerin., ^ss. 


R.     Ext.  grindeliae  robustae, f^ss 

Aquas  dest., Uj. 


These  last  may  be  applied  on  cloths  and  remain  until  dry. 

For  the  relief  of  itching,  cloths  wrung  out  of  hot  water,  laid 
on  in  succession,  are  of  use.  Carbolic  acid,  the  most  efficient 
antipruritic,  must  be  used  with  extreme  caution  in  the  acute 
stages.  It  may  be  added  to  the  black  wash  along  with  a  little 
glycerin,  and  is  always  useful,  but  only  free  from  some  danger  of 
absorption  and  poisoning  if  the  skin  is  unbroken.  Ointments  in 
certain  cases  suit  better  than  lotions.  Cold  cream  is  a  better  base 
for  ointments  for  children  than  lard  or  vaselin.  Oleate  of  zinc  is 
a  useful  addition  to  some  ointments  : 

R .     Zinci  oleat. , 

Ung.  aquae  rosae, 

Ol.  amygdalae, .      aa  5  ss. 

48 


754  DISEASES    OF    THE    SKIN. 

The  oleate  of  bismuth  and  the  saturated  solution  of  boric  acid 
are  also  recommended  ;  or  : 

H .     Resorcin, gr.  x 

Glycerin., Tt\,x 

Bismuthi  subnit., r  ss 

Liq.  calcis,       ....        ^3)- 

For  oozing  and  itching  areas  : 

li.      Bismuth,  oxid., ajj 

Acid,  oleic., gj 

Cera  alba, 3  iij 

Vaselin,       gix 

Ol.  rosse n\jj. 

Rub  the  oxid  of  bismuth  Avith  the  oleic  acid,  and  let  it  stand 
for  two  hours,  then  place  in  a  water-bath  until  the  bismuth  oxid 
is  dissolved.  Add  the  vaselin  and  wax,  and  stir  until  cold. 
Among  other  soothing  dressings  may  be  mentioned  cucumber 
ointment,  glycerol  of  starch,  a  pure  almond  and  olive  oil,  and 
diluted  glycerin,  one  part  to  four  or  six  of  boiled  or  distilled 
water.  • 

CHRONIC  ECZEMA. 

"  Acute  "  and  "  chronic,"  used  in  describing  state,s  of  eczema, 
are  misleading ;  we  may  have  an  "  acute  "  attack  on  top  of  an 
old  chronic  case  induced  by  digestive  or  other  disturbances. 
This  must  then  be  treated  as  an  acute  eczema  by  soothing  mea- 
sures only  until  this  feature  of  the  condition  is  under  full  control. 

In  most  cases  of  subacute  or  protracted  eczema  the  soothing 
treatment  used  in  the  acute  form  is  alone  suitable.  It  will  occa- 
sionally be  necessary,  however,  to  make  use  of  more  stimulating 
remedies.  Carbolic  acid  or  resorcin  are  then  the  most  valuable 
remedies.  Preparations  of  tar  are  to  be  used  with  caution,  as 
they  may  disagree  and  cause  more  inflammation,  and  are  more 
suited  to  the  inveterate  chronic  condition  where  there  are  des- 
quamation  and  more  or  less  infiltration.  The  portion  of  tar 
should  rarely  be  more  than  from  ten  to  forty  grains  to  the  ounce. 
The  form  may  be  the  pix  liquida  or  the  oleum  cadinum,  the 
effects  of  which  are  practically  identical. 

For  eczema  of  the  scalp  : 

K.     Hydrarg.  ammoniat., gr.  xx 

Petrolat., jf  j. 

The  red  oxid  of  mercury,  from  two  to  thirty  grains  to  the 
ounce,  is  useful.  A  mild  mercurial  ointment  is  the  ammoniated 
mercury,  from  ten  to  twenty  grains  to  the  ounce,  given  above, 
and  is  suitable  for  the  pustular  eczema  of  children. 


ECZEMA.  755 

Preparations  of  tar  must  be  thoroughly  rubbed  into  the  skin 
by  a  mop  or  the  fingers  of  an  attendant.  Soap  plays  an  impor- 
tant part  in  the  treatment  of  some  forms  of  eczema.  Ordinary 
washing-soaps  had  best  be  used  as  little  as  possible.  Strong 
alkaline  soaps  are  used  to  stimulate  stubborn  patches  or  to  re- 
move infiltrations.  A  useful  preparation  for  cleansing  areas  when 
covered  with  accumulated  crusts  and  scales  is  : 

R .     Sapo  viridis, rj  ij 

Alcohol.,    .    .  3J-ij- 

Dissolve  with  heat  and  filter. 

This  is  a  powerful  stimulant  and  cleanser,  rubbed  in  with  a 
mop,  taking  great  care  to  wash  it  all  thoroughly  out  again  with 
hot  water ;  the  surface  is  then  dried  with  soft  cloths,  and  a 
soothing  ointment  applied. 

Other  remedies  for  chronic  eczema  are  mercurial  preparations, 
useful  only  in  limited  areas  and  always  with  extreme  caution  : 

R  .     Hydrarg.  chlorid.  mit.,      gr.  v-xx 

Ung.  zinci  oxidi, 

Petrolat., aa^ss. 

Sulphur  and  resorcin  are  valuable  in  some  forms,  particularly 
in  eczema  seborrhoeicum,  in  ointments  of  from  ten  to  twenty 
grains  to  the  ounce  of  cold  cream.  Lassar's  paste  is  useful  here 
as  well  as  in  the  acute  forms.  (See  formula,  p.  753.) 

The  treatment  of  eczema  must  include  internal  medication  of 
such  a  kind  as  shall  correct  obvious  disturbances.  These  are 
mostly  digestive,  and  the  remedies  are  outlined  elsewhere.  It 
is  usually  important  to  make  occasional  use  of  laxatives  as  well, 
sometimes  in  quite  a  long  course,  especially  in  older  children. 
Diathetic  conditions,  such  as  uricacidemia,  are  frequently  a  fac- 
tor, or  vasomotor  disturbances  of  central  origin,  requiring  both 
internal  and  external  measures  for  their  relief.  Nutritional 
tonics  are  then  needed,  even  though  the  subject  exhibit  no 
obvious  deficiency. 

The  Use  of  Arsenic  in  the  Treatment  of  Eczema. — As  a  rule, 
this  drug  given  internally  causes  more  harm  than  good.  It  acts 
as  a  direct  nerve  stimulant  and  exerts  its  influence  on  the  mucous 
layer  of  the  epidermis.  In  the  acute  stages,  when  rapid  cell 
changes  are  taking  place,  accompanied  by  heat,  burning,  and 
intense  itching,  the  drug  should  never  be  administered,  as  it 
stimulates  the  already  inflamed  mucous  layer  when  rest  is  de- 
sired. Generally  speaking,  this  rule  holds  good  for  the  acute 
inflammatory  stages  of  any  disease  of  the  skin.  In  psoriasis,  for 
example,  the  drug  should  be  withheld  while  the  disease  is 


756 


DISEASES    OF    THE    SKIN. 


rapidly  spreading  and  until  the  acute  symptoms  have  subsided. 
Arsenic  is  never  to  be  used  against  the  skin-lesions  themselves, 
but  only  in  well-selected  cases,  when  the  underlying  cause  of  the 
disease  is  a  debilitated  or  run-down  condition  of  the  nervous 
system.  The  remedy  is  best  administered  to  children  in  the 
form  of  liquor  sodii  arsenitis,  ^4- to  2-minim  doses,  according  to 
age,  well  diluted.  This  solution  is  less  disturbing  to  the  diges- 
tive tract  than  the  potash  salt. 

Differential  diagnosis  may  be  made  between  eczema  and 
other  disorders  which  often  resemble  it  by  comparing  the  fol- 
lowing admirable  tables  (from  Van  Harlingen)  : 


ECZEMA  ERYTHEMATOSUM. 

1.  Not  contagious  ;  frequently  history 
of  eczema  elsewhere. 

2.  Accompanied  by  mild  symptoms. 

3.  Little  or  no  edema,  but  some  infiltra- 
tion, shown  by  the  thickness  of  the 
skin  on  pinching  up  a  roll  between 
the  fingers.       Surface  dull  and  red 
and  often  slightly  scaly. 

4.  Not  a  creeping   disease,   though   it 
may  spread  irregularly. 

5.  Inflammation   less   acute   and  more 
superficial. 

6.  Itching   perhaps  more  marked  than 
burning. 

7.  Not  apt  to  be  painful  on  pressure. 

8.  Not  infrequently   some  secretion  at 
one  stage  or  another. 

9.  Vesicles  form  early,  if  at  all. 

10.  Runs  a  chronic  course. 

11.  No  line  of  demarcation. 

12.  No  rise  of  temperature. 


ERYSIPELAS. 

1.  Frequent  history  of  contagion. 

2.  Well-marked    constitutional    symp- 

toms. 

3.  Shining  redness  ;  skin  tense  ;  marked 
edema. 


4.  A  creeping  eruption,  spreading  per- 
ipherally. 

5.  Inflammation  very  acute  and  deep- 
seated. 

6.  Intense  burning  and  little  pruritus. 

7.  Usually  very  painful  on  pressure. 

8.  No  discharge  except  from  ruptured 
blebs. 

9.  Vesicles,  or  rather  blebs,  form  late. 

10.  Runs  a  rapid  course. 

11.  A  distinct  line  of  demarcation. 

12.  Always  a  rise  of  temperature. 


ECZEMA  PAPULOSUM. 

1.  History  of  eczema. 

2.  Eruptions   may   appear   more  grad- 
ually. 

3.  Often  extensive. 

4.  Lasts  usually  for  weeks. 

5.  Absence  of  blood  crusts,  excepting 
in    connection    with     the    papular 
lesions. 

6.  Usually  accompanied  by  other  forms 
of  eczema. 

7.  Itching  severe.     Not  so  much  burn- 
ing as  pricking.      Not  so  markedly 
aggravated  by  currents  of  air,  etc. 


URTICARIA. 

1.  Often  a  history  of  error  in  diet,  or 
dyspepsia. 

2.  Eruptions  appear  suddenly. 

3.  Usually  not  extensive. 

4.  The  separate  attacks  may  last  but  a 
few  hours. 

5.  Frequent   presence  of  blood   crusts 
from  scratching  the  only  evidence  of 
the  disease. 

6.  Not  accompanied  by  other  forms  of 
eruption  elsewhere. 

7.  Itching,  tingling,  pricking,  and  burn- 
ing intense.     Usually  aggravated  by 
currents  of  cold  air,  undressing,  etc. 
Often  intense  nervousness. 


ECZEMA. 


757 


ECZEMA  PAPULOSUM. — ( Continued. ) 

8.  Eruption  remains  the  same  for  days. 

9.  Skin  not  especially  irritable. 


URTICARIA.  —  ( Continued. ) 

8.  Exacerbations    may   occur  in  a  few 
hours. 

9.  Welts  form  immediately  on  irritation 
of  the  skin. 


ECZEMA  VESICULOSUM. 

1.  Begins  with  slight  burning  or  itch- 
ing. 

2.  Vesicles  seldom  form  distinct  groups. 

3.  Vesicles  tend  to  run  together. 

4.  Vesicles  small. 

5.  Vesicles  tend  to  rupture. 

6.  Formation  of  crusts. 

7.  Eruption   accompanied   by  more   or 
less  intense  itching. 

8.  No  special  arrangement  of  lesions. 

9.  Eruption  occurs  on  both  sides. 


HERPES  ZOSTER. 

1.  Neuralgic  pains  a  premonitory  symp- 
tom. 

2.  Vesicles    are    arranged    in    distinct 
groups. 

3.  Vesicles   markedly  distinct  and    in- 
dependent. 

4.  Vesicles  large. 

5.  Vesicles    do   not   rupture   spontane- 
ously. 

6.  No  crusts   unless  vesicles  are    acci- 
dentally ruptured. 

7.  Burning  pain,  often  lancinating,  ac- 
companies the  eruption. 

8.  Eruptions  follow  the  course  of  some 
nerve. 

9.  Eruption  limited  to  one  half  of  the 
body. 


ECZEMA  SQUAMOSUM. 

1.  Presence  of  moisture  at  some  time. 

2.  Skin  red  and  thickened. 

3.  Scales  more  firmly  adherent. 

4.  Ears  frequently  attacked. 

5.  Alopecia  less  frequent,  and  the  hair 
usually  returns  after  the  eczema  is 
cured. 

6.  Hairs  frequently  matted  together. 


PITYRIASIS  CAPITIS. 

1.  Always  a  dry  disease. 

2.  Skin  not  thickened  nor  inflamed. 

3.  Scales  easily  detached. 

4.  Disease  limited  to  scalp. 

5.  Frequently   more    or    less   baldness 
ensues  after  a  time. 

6.  Hairs  surrounded  by  a  scaly  sheath. 


ECZEMA  SQUAMOSUM. 

1.  Eruption   fades  gradually  into   sur- 
rounding skin. 

2.  Scales  thin  and  scanty. 

3.  Presence  of  moisture  at  some  stage. 

4.  Lesions    change    in   character   from 
time  to  time. 

5.  Scales  small  and  yellowish. 

6.  Intense  itching. 

7.  Patches  of  eruption  large  and  irreg- 
ular. 

8.  No  seat  of  predilection. 

9.  No  uniformity  of  lesions. 

10.  Considerable  induration  of  patches. 

1 1 .  Ears  and  face  frequently  attacked  in 
eczema  of  the  scalp. 


PSORIASIS. 

1.  Patches  of  eruption  sharply  defined. 

2.  Scales  thick  and  abundant. 

3.  Eruption  always  dry. 

4.  Eruption    remains    the    same    from 
week  to  week. 

5.  Scales  large  and  pearl-like. 

6.  Itching  less  severe. 

7.  Patches    of    eruption    smaller    and 
round. 

8.  Seat  of  predilection  on  knees,  elbows, 
etc. 

9.  Great  uniformity  of  lesions. 

10.  Less  induration,  but  greater  vascu- 
larity. 

11.  When  affecting  scalp,  usually  limited 
to  hairy  parts,  just  extending  to  the 
edge  and  limited  by  an  abrupt  line 
of  demarcation. 


758 


DISEASES    OF    THE    SKIN. 


ECZEMA  PAPULOSUM. 

1.  No  desquamation. 

2.  Lesions  remain  papular  for  weeks. 

3.  Severe  itching. 

4.  Papules   rounded  and  more  or  less 
acuminate. 

5.  Papules  rounded  in  outline. 

6.  Color  of  lesions  bright  red. 

7.  Lesions  irregularly  arranged. 

8.  Little  or  no   subsequent  pigmenta- 
tion. 

9.  Papules    often    unite,    losing    their 
identity. 

10.   Health  remains  good  in  most  cases. 


LICHEN;  RUBER  PLANUS. 

1.  Desquamation. 

2.  Remain  papular  for  months. 

3.  Usually  slight  itching. 

4.  Papules  flat,  slightly  depressed,  and 
some  umbilication  in  the  center. 

5.  Papules  have  a  peculiar  squarish  or 
angular  outline. 

6.  Color  of  lesions  dull  red  or  viola- 
ceous. 

7.  Lesions   seem  sometimes  to  follow 
nerve-trunks. 

8.  Lesions  have  some  pigmentation  or 
staining. 

9.  Papules    retain    their    individuality, 
although  forming  patches. 

10.   Health  often  impaired. 


ECZEMA  SQUAMOSUM. 

1.  Redness  occurs  in  patches. 

2.  Intense  itching  and  some  burning. 

3.  Scales  small  and  bran-like. 

4.  Scales  form  slowly. 

5.  Skin  infiltrated  and  thickened. 

6.  Exudation  present  at  some  period. 

7.  Scales  not  very  abundant. 

8.  Affection  common. 

9.  General  health  remains  good. 


PlTYRIASIS  RUBRA. 

1.  Uniform  redness. 

2.  Slight  itching  and  no  burning. 

3.  Scales  large  and  papery. 

4.  Scales  reproduced  rapidly. 

5.  Skin  not  infiltrated. 

6.  Process  always  a  dry  one. 

7.  Scales  very  numerous. 

8.  Rare  disease. 

9.  Severe  constitutional  disturbance  after 
disease  has  lasted  some  time. 


ECZEMA  SQUAMOSUM. 

1.  Eruption  usually  irregular. 

2.  Margins  ill  defined. 

3.  Scaling  bran-like  and  abundant. 

4.  Not  contagious. 

5.  Irregular  character  of  eruption. 

6.  Does  not  heal  from  center. 

7.  Usually  a  chronic  affection. 

8.  Nonparasitic  disease. 


ECZEMA  PUSTULOSUM. 

1.  Nonparasitic  disease. 

2.  Not  communicable. 

3.  No  peculiar  odor. 

4.  Exudation  purulent. 

5.  No  permanent  loss  of  hair. 

6.  Hairs  appear  normal. 

7-  Eruption  never  ends  in  ulceration  or 
cicatrization. 

8.  Crusts  moist  and  sticky. 

9.  Acute  course  of  disease. 


TINEA  CIRCINATA. 

1.  Eruption  circular  in  form. 

2.  Margin  well-defined  and  raised. 

3.  Slight,  shreddy  desquamation. 

4.  Communicable. 

5.  Eruption  ring-shaped. 

6.  Tendency  to  heal  from  center. 

7.  Disease  runs  an  acute  course. 

8.  Presence    of    mycelium    under   the 
microscope. 

FAVUS. 

1.  Peculiar  vegetable  parasite  to  be  found 

in  abundance  under  microscope. 

2.  Contagious. 

3.  Lesions  have  a  characteristic  mouse- 
like odor. 

4.  Exudation  dry  and  powdery  ;  canary- 
yellow  lesions,  cup-shaped,  hair  pro- 
trudes through  center  of  cup. 

5.  Eruption  gives  rise  to  scars  and  alo- 
pecia. 

6.  Hairs  brittle,  dry,  and  wiry. 

7.  Disease  may  result  in  cicatrization. 

8.  Crusts  dry  and  friable. 

9.  Very  chronic  affection. 


ECZEMA. 


759 


ECZEMA  PAPULOPUSTULOSUM. 

1.  Nonparasitic  disease. 

2.  No  burrows. 

3.  Not  communicable. 

4.  Vesicles  and  pustules  confluent. 

5.  Eruption    sudden    and   not  progres- 
sive. 

6.  Vesicles  clear. 

7.  Pruritus  less  severe. 

8.  No  special  seat  of  election. 


9.  Scalp  may  be  affected. 

10.  Individual  lesions  usually  small. 

11.  Vesicles  usually  rupture. 

ECZEMA  ERYTHEMATOSUM 

1.  History  frequently  of  eczema. 

2.  Eruption  limited  in  extent. 

3.  Patches  of  eruption  quite  large. 

4.  Intense  itching. 

5.  Lesions  bright-red  color. 

6.  Usually  accompanied  by  other  forms 
of  eczema. 

7.  Slight  scaling,  but  no  pigmentation. 

8.  Skin  thickening. 


SCABIES. 

1.  Presence  of  parasites. 

2.  Presence      of     burrows,     pathogno- 
monic. 

3.  Very  contagious. 

4.  Vesicles,  papules,  and  pustules  dis- 

crete. 

5.  Eruption  progressive. 

6.  Irregular  dots  on  vesicles. 

7.  Itching  intense,  especially  at  night. 

8.  Lesions  found  especially  between  fin- 
gers, on  flexor  surface  of  the  wrists, 
on  anterior  folds  of  axillae,  about  nip- 
ples, on  shaft  or  head  of  penis,  but- 
tocks, popliteal  spaces. 

9.  Disease    very    rarely    affects    scalp ; 
this  does  not  apply  to  infants.* 

10.  Vesicles    and    pustules    often    very 
large. 

11.  Vesicles    do    not    rupture   spontane- 
ously. 

SYPHILODERMA  ERYTHEMATOSUM. 

1.  History  of  chancre. 

2.  Eruption  diffuse. 

3.  Individual  lesions  small. 

4.  Rarely  much  itching,  if  any. 

5.  Coppery,  fawn,  or  pale-rose  color. 

6.  Presence  of  other   syphilitic    symp- 
toms. 

7.  No  scaling,  but  pigmentation. 

8.  No  induration  of  the  skin. 


ECZEMA  PAPULOSUM. 

1.  History  of  eczema. 

2.  Eruption  usually  limited  in  area. 

3.  Superficial  eruption. 

4.  Eruption  usually  moist  at  one  time 
or  other. 

5.  Severe  itching. 

6.  Lesions  less  distinct. 

7.  Vesicles  not  infrequently  associated 
with  papules. 

8.  Lesions  more  acute  and  active. 

9.  Lesions  tend  to  group  and  unite. 


SYPHILODERMA  PAPULOSUM. 

1.  History  of  syphilis. 

2.  Eruption  extensive. 

3.  Eruption  deep-seated. 

4.  Eruption  dry  from  the  first. 

5.  Little  or  no  itching. 

6.  Lesions  have  a  firm,  shotty  feel. 

7.  Distinctly  papular. 

8.  Lesions  chronic  and  passive. 

9.  Lesions  usually  discrete. 


ECZEMA  SQUAMOSUM. 

1.  History  of  eczema. 

2.  Eruption  superficial. 

3.  Intense  itching. 

4.  Eruption    moist     at     one   time    or 
another. 


SYPHILODERMA  SQUAMOSUM. 

1.  History  of  syphilis. 

2.  Eruption  deep-seated. 

3.  Slight  itching. 

4.  No  discharge. 


*  In  infants  whose  scalps  and  faces  are  warm  and  moist  from  nursing  in  arms  and 
lying  in  cribs  the  mite  will  flourish  bravely. 


760 


DISEASES    OF    THE    SKIN. 


ECZEMA  SQUAMOSUM. — (Continued.) 

5.  Eruption  red  in  color. 

6.  Scales  abundant  and  thick. 

7.  Infiltrations    less   marked    and    in- 
flamed. 

8.  Margins  indistinct  and  not  abruptly 
elevated. 

9.  Heals  first  at  edges. 

10.  Lesions  active  and  inflammatory. 

11.  No  secondary  lesions   except  large, 
painful  glands   in   neighborhood  of 
eruption. 

12.  Eruption  has  an  irregular  outline. 


ECZEMA  PUSTULOSUM. 

1.  History  of  eczema. 

2.  Often  itching. 

3.  No  bad  odor. 

4.  No  ulceration. 

5.  No  scarring. 

6.  Eruption  usually  confluent  in  large 
patches. 

7.  Scales   less    prominent    and    never 
stratified. 

8.  Vesicles  present  at  some  stage. 

9.  Eruption  develops  rapidly  and  dis- 
appears sooner. 

10.  Crusts  moist. 

1 1.  Scales  less  adherent. 

12.  Absence  of  secondary  lesions. 


SYPHILODERMA  SQUAMOSUM. — (Con- 
tinued. ) 

5.  Eruption  ham-colored. 

6.  Scales  scanty  and  thin. 

7.  Infiltration    of     skin     marked     and 
cellular. 

8.  Margins     elevated     and     well    de- 
fined. 

9.  Tendency  to  heal  at  center. 

10.  Lesions  passive  and  but  slightly  in- 
flamed. 

11.  Presence  of  secondary  lesions. 


12.  Tendency  to  occur  with  circular  out- 
line. 

SYPHILODERMA  PUSTULOSUM. 

1.  History  of  syphilis. 

2.  Itching  absent  or  moderate. 

3.  Odor  very  disagreeable. 

4.  Ulceration  under  crusts. 

5.  Lesions  leave  scars. 

6.  Lesions  discrete  or  form  small,  irreg- 
ular patches  with  circular  outline. 

7.  Scales   prominent  and  often  in  the 
form  of  rupia  (oyster-shell  like). 

8.  Pustules  usually  occur  alone. 

9.  Lesions    develop    slowly    and    last 
long. 

10.  Crusts  dry. 

11.  Scales  adherent. 

12.  Presence  of  secondary  lesions. 


ERYTHEMA. 

Six  varieties  of  erythema  are  worthy  of  mention  :  Erythema 
simplex,  erythema  intertrigo,  erythema  vaccinium,  erythema 
variolosum,  erythema  multiforme,  and  erythema  nodosum. 

The  first  four  are  simply  hyperemias,  with  little  or  no  inflam- 
matory exudation,  while  the  last  two  are  characterized  by  more 
or  less  plastic  exudation.  They  all  terminate  without  leaving  a 
mark  or  scar.  Erythema  simplex  is  characterized  by  redness, 
occurring  in  patches,  from  whatsoever  cause,  in  form  of  variously 
sized,  diffused  or  circumscribed  areas. 

Varieties. — (i)  Irritations  caused  by  heat  or  cold,  pressure 
or  rubbing,  irritating  or  poisonous  substances  ;  (2)  symptomatic, 
due  to  some  systemic  disturbance,  as  disorders  of  the  digestion 
or  the  blood.  The  treatment  is  the  removal  of  the  obvious 
cause,  local  or  internal  ;  locally,  soothing  or  astringent  lotions  ; 
bran  decoction  with  soda  with,  it  may  be,  a  few  drops  of  carbolic 
acid.  The  calamin  lotion  has  a  wide  range  of  usefulness  : 


ERYTHEMA.  761 

R.      Pulv.  calamin.,  ..............  5j  iij 

Pulv.  zinci  oxidi,    ............  3  ij 

Glycerin.,    ...............  Tl\,xl 

Liq.  calcis, 

Aq.  rosze,     ..............    aa  f^ij. 

Ointments  are  apt  to  disagree  and  are  less  cleanly. 

Erythema  Intertrigo.  —  A  common  form  of  irritation  occur- 
ring on  the  natural  folds  of  the  skin  where  these  come  in  contact 
with  each  other  and  chafe,  as  about  the  buttocks,  groin,  and 
armpit.  The  skin  feels  hot  and  looks  sore  ;  perspiration  macer- 
ates the  epidermis  and  may  cause  an  acrid,  mucoid  discharge  ; 
the  cause  is  usually  mechanical,  by  the  rubbing  together  of  two 
surfaces  of  skin  or  the  contact  of  rough  clothing,  acid  urine, 
salt  sea-water,  sweat,  or  irritating  discharges. 

Erythema  intertrigo  in  an  infant  may  resemble  an  erythematous 
hereditary  syphiloderm,  and  an  opinion  should  not  be  hastily  ex- 
pressed. At  first  the  syphilitic  eruptions  disappear  under  pressure, 
but  in  the  course  of  a  few  weeks  the  lesions  become  more  marked, 
and  appear  in  other  portions  of  the  integument  than  the  natural 
folds,  the  lesions  becoming  infiltrated  and  change  in  color  to  a 
deep,  yellowish-red,  and  moist  papules  will  show  themselves. 
Mucous  patches,  fissures  of  mouth  and  anus,  sniffles,  hoarseness, 
wizened  appearance,  etc.,  will  readily  make  clear  the  diagnosis. 

The  treatment  is  cleanliness  and  care  to  keep  the  parts  asunder. 
Smooth  bits  of  linen  or  wads  of  absorbent  cotton  placed  in 
between  are  comforting  and  preventive. 

K.     Pulv.  acid,  boric.,     ............  gj 

Pulv.  talc.,    ................   j-j. 


This  is  a  powder  which  will  not  ferment.  Calamin  lotion  is  also 
useful. 

Certain  other  powders  are  useful  :  Oxid  of  zinc,  stearate  of 
zinc,  bismuth,  magnesia,  fullers'  earth,  and  calamin.  In  stubborn 
cases  black  wash  diluted  with  lime-water,  dilute  alcohol,  with 
alum  or  sulphate  of  zinc  (weak  solution  :  zinc  sulphate,  y2  to  two 
grains  ;  water,  one  fluidounce),  followed  by  a  powder,  are  useful. 
If  hyperhidrosis  occurs  about  the  genitalia,  etc.,  belladonna  may 
be  added  to  the  lotions.  If  the  digestion  of  a  child  is  disturbed, 
alkaline  laxatives  and  diuretics  may  be  given,  to  which  a  bromid 
may  be  advantageously  added. 

Infantile  erythema  (roseola),  common  in  infants  suffering 
from  gastric  disturbance  or  febrile  complaints,  occurs  chiefly  on 
the  trunk,  and  may  be  mistaken  for  scarlet  fever  or  measles. 

Erythema  vaccinium  (roseola  vaccinia)  occurs  frequently  a 
day  or  two  after  vaccination,  extending  over  the  trunk  and 


762  DISEASES    OF    THE    SKIN. 

extremities,  and  sometimes  induces  the  fear  of  syphilitic  infection. 
This  last  has  a  much  longer  incubation  period,  and  is  of  a  dusky 
red,  and  not  the  usual  fawn  color  of  the  syphiloderm. 

Erythema  variolosum,  one  of  the  prodromal  rashes  of 
smallpox,  appears  in  a  characteristic  locality,  over  the  abdomen 
and  inner  side  of  the  thighs,  the  dorsal  surfaces  of  hands  and 
feet,  and  the  axillae.  It  may  be  accompanied  by  redness  of  the 
pharynx.  In  a  few  days  the  diagnosis  will  be  made  clear. 

Erythema  multiforme  is  very  like  erythema  simplex,  but 
more  severe  ;  it  manifests  itself  as  erythematous  patches  of  most 
varied  shapes  and  sizes,  or  as  papules,  vesicopapules,  and  tuber- 
cles, scattered  or  in  groups.  The  papular  type  is  the  most 
common.  With  or  without  symptoms  of  malaise  or  rheumatic 
pains  the  lesions  appear  suddenly.  These  soon  fade  and  seldom 
last  longer  than  a  week  or  ten  days  ;  though  very  severe  look- 
ing, the  lesions  disappear  spontaneously,  leaving  perhaps  slight 
pigmentation  or  desquamation.  They  occur  symmetrically,  are 
usually  seen  on  the  backs  of  the  hands,  feet,  and  knuckles,  but 
may  be  more  or  less  general,  appearing  in  the  spring  and  fall. 
As  a  rule,  no  subjective  symptoms  are  complained  of. 

Erythema  iris  is  erythema  multiforme  when  we  have  a  play  of 
colors  in  the  lesions.  One  or  more  rings  concentrically  arranged 
may  appear,  giving  the  lesion  a  target-like  appearance. 

Herpes  iris  is  simply  erythema  iris  gone  on  to  vesication.  Here 
sufficient  serous  exudation  has  taken  place  to  raise  the  epidermis 
from  the  tissues  beneath  in  the  form  of  vesicles  or  bullae. 

The  treatment  of  erythema  multiforme  is  very  simple — quinin, 
salicylates,  mild  saline  laxatives  and  diuretics,  a  carbolic  acid 
wash,  one  to  three  drams  to  the  pint  of  camphor  water,  adding 
a  little  glycerin  and,  perhaps,  soda ;  dusting-powders  may  be 
used. 

Erythema  nodosum  is  an  inflammatory  disease  characterized 
by  rounded  or  oval,  more  or  less  elevated  reddish  nodes.  It  is 
ushered  in  by  some  systemic  disturbance  and  rheumatoid  pains, 
with  swellings  around  the  joints.  The  nodes  appear  suddenly 
on  any  part  of  the  body,  but  commonly  on  the  legs  and  arms, 
especially  over  the  tibia,  the  long  axis  of  the  node,  parallel  to  the 
long  axis  of  the  tibia  usually.  They  vary  in  size  from  that  of  a 
small  nut  to  that  of  an  egg,  are  usually  slightly  elevated,  are 
reddish  at  first,  tending  to  become  purple  or  blue,  and  as  they  dis- 
appear turn  yellow,  simulating  bruises.  When  the  nodes  are  at 
their  height  they  look  as  though  they  contained  fluid,  and  they 
may  be  hemorrhagic.  They  never  suppurate.  The  disease  oc- 
curs most  frequently  in  children  and  young  adults.  The  lesions 


FURUNCLE.  763 

come  out  in  crops  from  a  few  to  a  dozen  or  more,  usually  at- 
tended by  a  sensation  of  heat,  and  are  tender  on  pressure.  The 
duration  is  from  one  to  four  weeks. 

The  treatment  is  constitutional  and  local.  Salicylates  are 
called  for  and,  locally,  soothing  applications — lead-water  and 
laudanum,  hot  fomentations.  Rest,  absolute  or  relative,  accord- 
ing to  the  severity  of  the  attack  and  the  region  affected,  is  indi- 
cated. 

FURUNCLE. 
Synonym.— BOIL. 

Furuncle,  commonly  known  as  boil,  is  a  deep-seated  inflam- 
matory disease  characterized  by  one  or  more  variously  sized, 
circumscribed,  large  or  small  rounded  or  acuminated,  firm,  painful 
formations,  usually  terminating  in  a  central  suppuration.  Boils 
may  occur  singly,  in  groups,  or  often  in  successive  crops.  The 
lesion  begins  as  a  small,  ill-defined  red  spot  in  the  true  skin,  ten- 
der and  painful  from  the  first,  becoming  larger,  elevated,  and  show- 
ing a  tendency  to  suppurate  about  the  center.  It  matures  in  about 
a  week  or  ten  days  in  a  slightly  raised  or  pointed  formation,  with 
a  suppurating  center,  called  the  core.  This  core  may  not  form,  and 
it  is  then  called  a  "  blind  "  boil.  It  usually  produces  a  dull,  throb- 
bing pain,  which  increases  until  suppuration  takes  place,  and  then 
subsides.  Sometimes  there  is  sympathetic  constitutional  distur- 
bance ;  neighboring  glands  may  be  enlarged.  Boils  not  seldom 
occur  in  the  course  of  other  diseases,  and  occasionally  at  certain 
seasons,  as  in  the  spring  and  autumn,  appearing  as  an  epidemic. 
Boils  differ  from  anthrax  or  carbuncle  in  having  but  one  point  of 
suppuration  ;  the  carbuncle  has  many,  is  flat,  varies  in  size  from 
half  an  inch  to  four  inches  in  diameter,  and  while  painful,  is  not 
tender,  as  furuncle  is. 

Frequently  in  children  there  occurs  the  condition  known  as 
furunculosis,  or  crops  of  usually  small  pea-  to  bean-sized  or  larger 
phlegmonous  papules  or  papulopustules.  These  run  their  course, 
fresh  crops  appear,  and  thus  the  process  continues,  sometimes 
for  long  periods,  if  untreated.  These  boils  do  not  form  any 
definite  group  ;  they  are  usually  scattered  over  one  or  several 
portions  of  the  body,  are  usually  isolated,  and  occur  on  the  trunk, 
limbs,  forehead,  and  scalp.  They  are  frequently  connected  with 
excessive  sweating.  We  have  seen  them  in  infants  follow  an 
attack  of  miliaria  papulosa  (prickly  heat),  and  exist  in  consider- 
able numbers. 

Treatment. — The  object  is  to  destroy  the  cocci  in  each  boil, 


764  DISEASES    OF    THE    SKIN. 

and  thereby  exhaust  the  supply.  Open  the  pustules  surgically 
and  gently  express  the  pus  (rough  handling  of  a  small  boil  may 
readily  convert  it  into  a  large  one),  after  which  apply  three  or 
four  times  daily  the  following,  which  we  have  used  with  marked 
benefit  and  can  highly  recommend  : 

&.     Ichthyol,      n\,xx 

Acid,  boric., gr.  xv 

Aq.  destil.,      fgj. 

M.      SlG. — Apply  to  surface,  using  an  atomizer. 

Used  thus,  the  application  causes  no  pain  to  the  infant  or  re- 
sistance of  the  little  sufferer,  and  new  crops  will  not  appear,  as 
the  soil  is  made  unfavorable  to  the  growth  of  the  staphylococci. 

The  disease  is  regarded  as  due  to  the  micrococci,  especially 
the  staphylococcus  aureus,  invading  the  sweat-glands  or  hair 
follicles.  The  soil  also  must  be  favorable  for  their  development. 

Since  the  staphylococcus  pyogenes  aureus  has  been  demon- 
strated to  be  the  cause  of  boils,  parasiticides  have  come  into  use. 

The  following  plaster  spread  on  and  kept  in  place  is  claimed 
to  be  of  use  : 

U.    Ackl.  salicylic., ^ij 

Emplast.  sapon., 5  ij  ' 

Emplast.  diachyl.,        3J. 

SlG. — Spread  on  cloth  or  kid,  a  crossed  slit  to  be  cut  in  this  over  the  apex 
of  the  boil. 

Ichthyol  ointment,  12.5  to  25  per  cent.,  in  lanolin  and  petro- 
latum, rubbed  in  persistently  for  ten  minutes,  is  one  of  the  best 
means  of  aborting  the  local  inflammation.  When  pus  has  once 
been  formed,  free  incision  should  be  made.  Bulkley  praises  a 
mixture  of — 

R.    Acid,  carbolic., gr.  x 

Ext.  ergot,  fluid., 3J-ij 

Ung.  zincioxid., ^ij-iv. 

Peroxid  of  hydrogen  is  then  useful,  not  only  as  a  cleanser,  but 
as  an  antiseptic.  This  had  best  be  applied  in  full  strength  upon 
absorbent  cotton,  at  the  end  of  a  probe  or  stick  or  wire  applica- 
tor. If  poultices  are  used, — and  they  are  often  a  great  com- 
fort,— they  should  contain  boric  acid  and,  possibly,  laudanum. 


HERPES    ZOSTER. 
Synonyms. — ZONA  ;  SHINGLES. 

Zona,  or  shingles,  is  an  acute  inflammatory  disease,  character- 
ized by  groups  of  vesicles  seated  upon  inflamed  bases,  following 


HERPES    ZOSTER.  765 

the  distribution  of  cutaneous  nerves  and  accompanied  by  more 
or  less  neuralgic  pain.  The  vesicles  vary  in  size  from  that  of  a 
pinhead  to  that  of  a  split  pea,  and  they  may  coalesce,  but  the 
patches  do  not  show  this  tendency.  The  eruption  is  almost 
always  unilateral,  and  occurs  over  an  easily  traced  nerve-trunk. 
New  lesions  continue  to  appear  until  the  fourth  or  eighth  day, 
remaining  thus  a  few  days,  then  gradually  dry  up,  leaving  brown 
crusts.  Ten  to  twenty  days  is  the  average  duration  of  an  attack. 
The  distress  may  be  very  slight  or  overpowering.  These  neu- 
ralgic pains  occurring  before  the  eruption  manifests  itself  may 
give  rise  to  the  diagnosis  of  pleurisy,  pleurodynia,  or  other  local- 
ized suffering  until  the  characteristic  eruption  of  zoster  makes  the 
diagnosis  clear.  Of  late  years  herpes  zoster  is  being  regarded  as 
a  more  complicated  affection  than  it  was  for  a  long  time  believed 
to  be.  The  causal  factors  are  :  (i)  Inflamed  state  of  the  nerves, 
ganglia,  nerve-trunks,  branches,  or  filaments  ;  (2)  season — most 
frequent  in  winter  ;  (3)  sudden  temperature  change  ;  (4)  infec- 
tion ;  (5)  internal  use  of  arsenic  (Hutchinson)  ;  (6)  traumatism 
following  injuries  or  surgical  operations. 

The  diagnosis  of  herpes  zoster  can  be  made  upon  the  pro- 
dromal neuralgic  pain,  but,  as  a  rule,  this  is  absent  in  the  young  ; 
the  vesicles  tend  to  cluster  in  distinct  groups  upon  a  highly  in- 
flammatory base,  and  occur  on  a  nerve  tract,  and  unilaterally 
almost  always,  and  the  vesicles  preserve  their  form  intact.  In 
eczema  the  lesions  exude  moisture,  break  down,  and  form  crusts  ; 
in  herpes  zoster  there  is  no  discharge  unless  the  vesicles  are  rup- 
tured ;  they  dry  up  and  form  crusts.  Eczema  itches  ;  herpes 
zoster  burns. 

The  treatment  of  herpes  zoster  is  largely  palliative  ;  it  is  an 
acute,  self-limited  disease,  running  a  very  variable  course.  The 
neuralgic  pain  in  children  may  be  entirely  absent,  and  if  it  is 
present,  is  liable  to  subside,  as  the  eruption  becomes  established. 
The  main  points  are  to  prevent  the  vesicles  from  rupturing,  to 
exclude  the  air,  and  to  prevent  the  irritation  of  the  clothing. 
Internally,  the  coal-tar  analgesics  are  usually  efficacious  to  con- 
trol the  pain.  A  powder  of  acetanilid  or  phenacetin  three  grains, 
bicarbonate  of  soda  two  grains,  caffein  ^  grain,  codein  -^  to 
^  grain,  every  three  hours,  is  useful  for  a  child  of  ten  ;  sometimes 
morphin  is  necessary.  Bromids  may  be  needed  where  nervous- 
ness is  extreme. 

R.     Pulv.  camphorse, gr.  x 

Pulv.  talc, f  j. 

SIG. — Use  locally. 


766  DISEASES    OF    THE    SKIN. 

The  dusting-powder  should  be  very  freely  applied  to  the 'sur- 
face and  held  in  place  by  a  large  wad  of  cotton-wool  to  keep  the 
whole  from  being  moved  about  on  the  hypersensitive  surface,  and 
to  avoid  rupturing  the  vesicles,  as  infection  may  take  place  in  the 
broken-down  lesions  and  scarring  result. 

For  localized  patches  menthol  or  resorcin  in  gutta-percha  or 
collodion  are  excellent  protectives.  For  extensive  areas,  espe- 
cially about  the  gluteal  folds,  in  the  axillae,  lotions,  as  of  laud- 
anum, laudanum  and  lead-water,  or  fluid  extract  of  grindelia 
robusta,  diluted  with  water,  give  comfort.  On  limbs  which  must 
be  used  ointments  can  be  made  to  serve  a  good  turn,  or  oil  of 
peppermint  or  chloral  camphor  painted  on,  over  which  a  large 
shielding  wad  of  cotton  should  be  placed  and  firmly  attached. 

An  important  point  in  treatment  is  the  residual  neuritis,  for 
which  galvanism  gives  relief,  or  sometimes  blisters  on  the  central 
side  of  the  nerve  affected  are  useful. 


IMPETIGO  CONTAGIOSA. 

Impetigo  contagiosa  is  a  highly  contagious,  autoinoculable 
disease,  very  common  among  children  and  almost  entirely  conr 
fined  to  them,  running  its  course  in  about  ten  days  or  two  weeks, 
and  tending  toward  recovery.  It  may  be  defined  more  accur- 
ately as  an  acute,  inflammatory,  contagious  disease,  characterized 
by  the  formation  of  one  or  more  superficial  lesions,  round  or  oval 
in  shape,  beginning  as  vesicles  and  rapidly  becoming  pustules 
which  pass  into  crusts.  At  first  the  vesicles  stand  alone  and  are 
small  in  size,  but  soon  spread  out  until  they  become  the  size  of 
a  small  coin,  over  the  top  of  which  is  spread  out  a  thin  mem- 
brane, soon  becoming  collapsed  and  withered  looking.  There 
may  be  few  or  many  of  these,  alone  or  coalescing,  especially 
about  the  angles  of  the  mouth  and  around  the  ears  or  nose.  In 
a  few  days  yellowish  or  straw-colored  crusts  form  which  have  the 
appearance  of  being  loosely  "  stuck  on  "  the  skin,  and  are  readily 
pulled  off,  leaving  a  moist,  bleeding,  or  inflamed  surface  under- 
neath. The  course  is  about  ten  days,  but  we  have  seen  it  run 
along  for  weeks  in  much  the  same  locality,  doubtless  by  pro- 
gressive autoinoculations.  This  last  is  a  very  common  method 
of  extension,  and  we  have  frequently  seen  painful  lesions  on  the 
body,  about  the  buttocks,  or  under  the  armpits,  and  particularly 
on  the  lower  leg,  which  could  be  directly  traced  to  an  earlier 
mild  attack  of  impetigo  beginning  upon  the  face,  for  which  no 
treatment  had  been  sought.  The  cause  is  staphylococci  flour- 
ishing on  a  favorable  soil.  Impetigo  is  so  well  marked  a  dis- 


MILIARIA.  767 

order  in  its  distribution,  occurring  as  it  does  usually  on  the  face 
and  hands  and  beginning  as  flat,  flaccid  vesicles  or  vesicopustules, 
the  dirty  appearance  of  the  pustules,  the  yellowish-brown,  loosely 
attached  scabs  or  crusts,  the  absence  of  itching,  there  are  so 
constantly  two  or  more  children  in  a  family  affected  with  it  at 
the  same  time,  or  there  is  an  easily  obtainable  history  of  neigh- 
boring infection — that  there  should  be  little  difficulty  in  differen- 
tiating it  from  pustular  eczema,  scabies,  or  that  rare  and  illu- 
sive entity  known  as  simple  impetigo. 

Treatment. — Impetigo  contagiosa  may  get  well  of  itself  if 
left  alone  ;  but  this  the  child  will  not  do,  but  cherishes  it  and 
extends  it  all  over  his  person  by  his  hands  or  finger-nails,  or 
transfers  it  to  his  little  companions.  It  is  important,  then,  to  use 
some  cleansing  measures,  of  which  soap  and  water  do  very  well, 
but  antiseptic  washes,  such  as  boric  acid  solution,  are  even  better. 
There  is  no  itching  to  contend  with.  Ammoniated  mercury, 
from  ten  to  twenty  grains  to  the  ounce  of  boric  acid  ointment, 
will  usually  suffice.  The  removal  of  the  crusts  and  the  applica- 
tion of  some  astringent  antiseptic  wash  or  ointment  to  the  moist, 
inflamed  surface  will  hasten  the  cure.  As  the  seat  of  the  dis- 
ease is  very  superficial,  mild  antiseptic  applications  only  should 
be  prescribed. 

MILIARIA. 

Synonyms. — SUDAMINA  ;    MILIARIA    CRYSTALLINA  ;  MILIARIA   Ru- 
BRA  ;  MILIARIA  ALBA  ;  LICHEN  TROPICUS  ;  PRICKLY  HEAT. 

Miliaria  is  an  affection  due  to  an  obstruction  of  the  sweat- 
ducts,  either  with  or  without  inflammation.  Sudamina,  or  miliaria 
crystallina,  is  the  noninflammatory  form.  The  fluid  contained  in 
the  vesicles  is  pure  sweat.  Owing  to  the  orifice  of  the  duct 
being  plugged  by  an  obstruction,  the  sweat  is  effused  under  the 
horny  layer.  The  vesicles  are  pinpoint  to  pinhead  in  size,  closely 
crowded,  but  rarely  confluent ;  their  color  is  clear  or  pearly, 
and  they  occur  mostly  on  the  neck,  chest,  and  abdomen.  They 
resemble  dewdrops.  This  variety  occurs  often  in  the  course  of 
typhoid  and  rheumatic  fevers,  especially  by  a  "  critical  sweat- 
ing." The  fluid  is  absorbed  in  a  few  days,  leaving  slight  des- 
quamation. 

Miliaria  Rubra  et  Vesiculosa. — This  is  the  inflammatory 
form.  The  inflammation  may  be  primary  or  secondaiy,  and 
develops  in  the  sweat-pore  area.  When  we  have  bright-red 
papules  only,  it  is  miliaria  rubra ;  when  we  have  vesicles  or  pus- 
tules on  the  summits  of  the  lesions,  it  is  miliaria  alba. 


768  DISEASES    OF    THE    SKIN. 

The  lesions  occur  chiefly  on  the  trunk,  are  pinpoint  to  pinhead 
in  size,  closely  crowded,  but  discrete.  There  is  usually  a  diffuse 
redness  of  the  affected  area  ;  more  or  less  itching  is  complained 
of,  most  marked  in  the  papular  variety. 

The  affection  runs  its  course  in  a  few  days,  leaving  slight  des- 
quamation,  though  successive  crops  may  continue  to  appear. 
"  Red  gum,"  or  strophulus,  of  infants  is  miliaria  rubra  due  to  too 
warm  clothing. 

Miliaria  papulosa,  "prickly  heat,"  or  lichen  tropicus,  is 
another  variety  of  miliaria  rubra.  Here  the  inflammatory  pro- 
cess is  primarily  in  the  sweat-glands  and  causes  obstruction  of 
the  sweat-ducts.  The  eruption  consists  of  bright-red,  minute, 
closely  crowded,  but  not  confluent  acuminate  papules,  with  a  few 
vesicles  and  vesicopapules  scattered  about  between  them.  The 
eruption  is  preceded  by  profuse  sweating,  comes  out  suddenly, 
and  is  attended  with  intense  itching  and  pricking.  It  mostly 
affects  covered  parts — trunk,  limbs,  and  upper  part  of  forehead — 
and  is  usually  extensive.  Prickly  heat  is  most  common  in  the 
tropics,  but  occurs  in  America  during  the  summer.  Too  warm 
or  ill-fitting  clothing,  the  irritation  of  clothing,  especially  flannel, 
rapid  alterations  of  temperature,  seem  to  be  predisposing  factors. 
Children,  fat  people,  and  those  who  perspire  freely  are  most  liable 
to  it.  One  attack  predisposes  to  another. 

Diagnosis. — The  noninflammatory,  pearly  vesicles  of  sudam- 
ina  can  scarcely  be  confounded  with  anything  else.  Miliaria 
vesiculosa  may  be  mistaken  for  vesicular  eczema,  but  in  the  latter 
the  vesicles  rupture  spontaneously  ;  they  form  in  patches,  oozing 
is  usually  marked,  and  the  process  has  a  distinct  tendency  to 
spread,  and  is  more  chronic  in  its  course.  Miliaria  papulosa, 
occurring  only  in  hot  weather,  its  sudden  onset,  associated  with 
excessive  sweating  and  the  eruption  confined  to  the  sweat-glands, 
the  minute  papules,  peculiar  pricking  instead  of  intense  itching 
sensations — all  differentiate  this  from  eczema  papulosa. 

Differential  Diagnosis. — Sweat  rashes  occurring  in  children 
are  liable  to  be  mistaken  for  some  of  the  exanthemata,  but  the 
absence  of  the  usual  constitutional  symptoms  of  measles,  scarla- 
tina, and  Rotheln,  and  keeping  in  mind  the  localization  of  the 
eruption  and  the  accompanying  sweating,  will  usually  make  the 
diagnosis  clear. 

The  prognosis  is  good,  the  disorder  generally  yielding  to 
appropriate  treatment. 

Treatment. — Saline  diuretics — acetate  and  nitrate  of  potash— 
and  lemon-  and  lime-juice  drinks  are  very  useful.  Locally,  alka- 
line and  bran  baths  (see  p.  750)  are  beneficial  ;  soothing,  cool- 


PEDICULOSIS.  769 

ing,  or  evaporating  lotions  will  afford  relief.  We  have  used  with 
marked  benefit  the  lotion  of  resorcin  and  bismuth  (see  Eczema) 
and  the  calamin  lotion.  (See  Erythema.)  Dusting-powders  of 
zinc,  starch,  and  boric  acid  are  useful. 


PEDICULOSIS. 

Pediculosis  (lousiness)  is  a  parasitic  affection  caused  by  the 
presence  of  lice.  There  are  three  varieties  of  pediculi — of  the 
head,  body,  and  pubes.  The  diagnosis  is  easy,  and  the  scratch- 
marks  must  be  carefully  searched  for.  In  the  scalp  and  pubes 
nits,  or  ova,  will  be  conspicuous.  The  parasite  attacks  the  scalp 
and  produces  considerable  irritation,  which  causes  the  patient  to 
scratch  ;  then  follows  effusion  of  serum,  blood,  or  pus,  the  hairs 
becoming  matted  together.  Pediculosis  is  a  common  cause  of 
eczema  in  the  back  of  the  head.  Sometimes  a  characteristic  form 
of  eczematous  eruption  can  be  seen  about  the  mouth,  nostrils, 
and  ears,  due  to  lice,  but  closely  resembling  impetigo  contagiosa. 

The  treatment  for  head-lice  is  to  apply  kerosene  or  tincture 
of  cocculus  indicus  overnight,  and  wash  the  hair  with  soap  and 
wrater  in  the  morning.  This  will  kill  the  insects,  but  does  not 
destroy  the  nits.  Vinegar  applied  will  soften  the  ova  and  aid  in 
their  removal.  The  hair  need  not  be  cut  if  care  and  patience  are 
used  in  applying  the  remedies. 

Body-lice  produce  considerable  itching,  which  is  usually  fol- 
lowed by  extensive  scratches.  Cleanliness  with  soap  and  water 
is  usually  sufficient  in  the  care  of  children  ;  the  underclothing 
must  be  baked  or  boiled.  This  insect  lives  in  the  clothing,  and 
only  goes  to  the  body  to  feed.  A  carbolic  lotion  may  be  neces- 
sary to  relieve  itching. 

The  crab-louse,  though  usually  found  on  the  pubes  in  the 
adult,  is  sometimes  met  in  the  other  hairy  parts,  as  the  axillae, 
but  is  only  rarely  met  in  children,  and  then  in  the  eyebrows  and 
eyelashes.  This  insect  may  be  removed  by  cocculus  indicus  of 
full  strength  or  diluted  one-half,  followed  by  vinegar  or  hot 
soapsuds,  or,  better, 

R .      Hydrarg.  bichlor. , gr.  j 

Acid.  acet.  glacial tt\,xx 

Aquae,      ad  ^j. 

M.     Sic. — Apply. 

This  is  the  most  neat  and  elegant  preparation,  as  the  bichlorid 
destroys  the  insect  and  the  acetic  acid  dissolves  the  nit,  which 
can  then  be  readily  removed  by  a  fine-toothed  comb. 
49 


770  DISEASES    OF    THE   SKIN. 


PITYRIASIS  ROSEA. 

Pityriasis  rosea  is  a  slight  affection,  self-limited  and  harmless, 
but  worth  mentioning  because  it  is  frequently  mistaken  for  more 
important  disorders.  It  is  characterized  by  discrete  or  con- 
fluent macular  or  maculopapular  lesions,  from  a  pea  to  a  half- 
dollar  size  ;  in  color  a  rosy  or  pale  red,  with  a  more  or  less  tawny  or 
yellowish  tint.  The  surface  may  be  slightly  or  not  at  all  raised, 
always  dry  or  scaly,  healing  in  the  center  and  spreading  at  the 
edge,  and  when  there  is  caused  a  ring-like  appearance,  it  may 
be  confounded  with  tinea  circinata.  The  eruption  is  usually 
seen  under  the  clavicles,  on  the  side  of  the  chest,  or  between 
the  shoulders.  It  may  be  mistaken  for  syphilis,  tinea  versicolor, 
tinea  circinata,  or  seborrhcea  corporis  ;  it  may  last  from  one  to 
three  months.  It  is  not  contagious,  and  requires  little  treatment, 
except,  perhaps,  a  mild,  stimulating  ointment  such  as — 

R.     Acid,  salicylic., gr.  x 

Sulph.  prsecip.,       gr.  xx 

Ung.  aq.  rosae, 3J. 

PSORIASIS. 

Psoriasis  is  a  chronic  inflammatory  disease  of  the  skin,  com- 
monly showing  itself  in  the  form  of  variously  sized  scaly 
patches  scattered  over  different  parts  of  the  body  ;  these  patches 
are  usually  rounded,  sharply  defined,  and  are  covered  by  a  mass  of 
imbricated  "  mother-of-pearl  "  scales  on  a  red  base.  When  the 
scales  are  picked  off,  there  is  shown  underneath  a  smooth,  shiny, 
reddish  surface,  on  which  may  be  seen  a  few  bleeding  points. 
Psoriasis  is  always  dry  and  scaly,  never  moist.  It  may  occur  in 
any  part  of  the  body,  but  most  commonly  on  the  extensor  sur- 
faces of  the  limbs,  and  especially  on  the  knees  and  elbows.  The 
back  is  a  favorite  situation,  and  it  is  frequently  seen  in  the  scalp. 
It  is  noncontagious,  and  may  occur  in  healthy,  well-nourished 
people  or  those  who  are  slightly  rheumatic.  It  is  almost  always 
symmetric  ;  there  is,  as  a  rule,  little  or  no  sense  of  itching. 
In  children  the  lesions  are  usually  small  and  rather  generally 
distributed.  The  elbows,  knees,  and  scalp  are  liable  to  be  the 
first  parts  attacked.  A  diagnosis  needs  to  be  made  between 
psoriasis,  seborrhea,  eczema,  and  syphilis.  In  seborrhea  of  the 
scalp  the  scales  are  greasy  and  yellowish  and  they  are  not  situ- 
ated on  an  inflammatory  base,  and  are  limited  to  that  region, 
and  the  scaling  or  crusting  is  diffuse  and  not  in  patches. 
In  psoriasis  the  scales  are  usually  profuse  and  mother-of-pearl 


colored,  and  are  situated  on  inflammatory  bases  and  occur  in 
patches  which  are  circumscribed.  Psoriasis  is  hardly  ever  con- 
fined to  the  scalp,  other  lesions  being  found,  especially  on  the 
extensor  surfaces  of  the  knees  and  elbows.  In  the  squamous 
syphilids  it  should  be  noted  that  these  are  rarely  confined  to  the 
joints  and  extensors,  where  patches  of  psoriasis  in  children  are 
usually  seen. 

The  prognosis  is  favorable  for  the  cure  of  the  existing  lesions, 
but  as  the  disease  is  very  liable  to  recur  sooner  or  later,  a  guarded 
opinion  as  to  ultimate  cure  must  be  given. 

Treatment. — Internally  the  chief  remedy  is  arsenic,  which  is 
of  undeniable  value  and  is  well  borne  by  children.  It  should 
not  be  prescribed  until  the  acute  inflammatory  symptoms  have 
subsided  and  while  the  disease  is  rapidly  spreading.  The  scales 
should  be  removed  before  local  treatment  is  attempted.  This 
may  be  accomplished  by  rubbing  in,  with  a  rag,  sapo  viridis  and 
hot  water,  or  by  the  prolonged  use  of  a  hot-water  and  soda  bath. 

About  the  face  and  the  scalp  a  good  ointment  is  ammoniated 
mercury,  twenty  to  forty  grains  to  the  ounce  of  lanolin  and  cos- 
molin.  Chrysarobin  is  most  efficacious,  but  should  be  used  with 
caution,  as  it  may  set  up  a  spreading  dermatitis.  A  good  appli- 
cation is  : 

R.     Chrysarobin.,      gr.  x 

Acid,  salicylic., gr.  xx 

Liquor  gutta  perchse, ^j. 

SIG. — Apply  with  a  camel' s-hair  pencil  every  third  or  fourth  day,  to  be  fol- 
lowed by  a  bath. 

Another  good  application  is  tar,  one  to  four  drams  to  petrola- 
tum one  ounce. 

PURPURA. 

Purpura  consists  in  the  development  of  variously  sized  and 
shaped  reddish,  usually  nonelevated  hemorrhagic  patches,  not 
disappearing  under  pressure.  The  several  varieties  of  purpura 
are  :  (i)  Purpura  simplex;  (2)  purpura  rheumatica ;  (3)  purpura 
hsemorrhagica. 

Purpura  Simplex.  —  Rarely  any  premonitory  symptoms; 
apparently  spontaneous  hemorrhages  make  their  appearance 
suddenly,  often  during  the  night.  They  most  frequently  appear 
on  the  lower  extremities,  especially  on  the  flexures,  but  Croker 
has  observed  them  in  children  occurring  first  upon  the  neck  and 
upper  part  of  the  back,  and  even  in  the  mouth.  The  lesions 
are  pin-  to  pea-  or  bean-sized  and  do  not  fade  on  pressure  ;  they 
are  usually  rounded  or  oval,  but  may  be  irregular  in  shape. 


772  DISEASES    OF    THE    SKIN. 

Usually  they  are  symmetric  and  come  out  in  crops.  At  first  they 
are  bright  red.  This  redness  gradually  fades  to  purple,  bluish 
green,  or  dirty  yellow  (the  same  changes  that  take  place  in  an 
ordinary  bruise).  They  disappear  slowly  by  absorption,  leaving 
a  temporary  pigmentation. 

The  course  of  this  variety  varies  from  a  few  days  to  a  few 
weeks. 

Prognosis. — Go  o  d . 

Treatment. — Locally  none  is  usually  required.  Rest  in  bed  is 
advisable  for  a  few  days.  * 

Purpura  Rheumatica  (Peliosis  Rheumatica). — This  is, 
like  some  cases  of  erythema  nodosum,  an  affection  of  rheumatic 
nature.  The  cutaneous  lesions  are  secondary  to  the  consti- 
tutional conditions  underlying.  The  disease  is  usually  ushered 
in  by  more  or  less  fever,  loss  of  appetite,  depressed  spirits,  and 
severe  rheumatic  pains,  especially  about  the  joints  of  the  lower 
extremities. 

In  a  few  days  the  purpuric  spots  appear  in  patches,  especially 
in  the  region  of  the  joints,  in  which  the  pain  is  most  severe. 
When  the  eruption  appears,  the  pain  in  the  joint  frequently 
abates  or,  it  may  be,  entirely  ceases.  The  patches  are  bright 
red  at  first,  but  do  not  fade  on  pressure.  They  disappear,  as  in 
purpura  simplex,  changing  color,  becoming  purplish,  etc.,  as  in 
a  bruise.  This  disease  usually  occurs  in  middle  age,  but  it  is 
not  unknown  in  children.  It  can  hardly  be  confounded  with 
any  other  disease,  as  the  combination  of  pain  in  the  joints  with 
cutaneous  hemorrhages  makes  the  diagnosis  clear. 

Cardiac  trouble  may  arise  in  the  course  of  this  disease  and 
may  become  permanent. 

The  prognosis  for  uncomplicated  cases  is  good.  If  grave  com- 
plications are  present,  a  guarded  one  is  to  be  given. 

Treatment. — Rest  in  bed.  Getting  up  too  soon  may  cause  a 
recurrence  of  the  hemorrhages  and  pains.  Salicylates  are  in- 
dicated and  should  be  pushed.  Quinin,  iron,  and  a  liberal  diet 
should  be  prescribed,  and  strict  attention  must  be  paid  to  the 
hygiene. 

Purpura  Haemorrhagica  (land  scurvy)  may  develop  from 
purpura  simplex,  and  it  may  be  regarded  as  a  severe  and  exag- 
gerated case  of  the  same.  Usually  premonitory  symptoms  of 
a  decided  character  usher  in  this  affection — headache,  general 
debility,  and  even  convulsions  (Crocker).  The  spots  generally 
appear  suddenly  on  limbs  ;  the  mucous  membranes  are  also  in- 
volved— mouth,  nose  ,  bladder,  vagina,  etc.  These  hemorrhages 
may  be  so  profuse  as  to  lead  to  exhaustion  or  death,  or,  on  the 


SCABIES.  773 

other  hand,  they  may  be  moderate.  They  may  continue  for  a 
few  weeks  or  so,  or  gradually  cease  altogether. 

This  type  of  purpura  is  usually  seen  in  debilitated  subjects  or 
in  those  in  a  depraved  state  of  health. 

Treatment. — Enforce  absolute  rest  in  bed  ;  sustain  the  strength 
by  nourishing  and  easily  assimilable  diet.  Ice  internally  and  ex- 
ternally may  be  useful.  Calcium  chlorid,  owing  to  its  property 
of  increasing  the  coagulability  of  the  blood,  has  lately  been 
highly  recommended  in  doses  of  from  ten  to  twenty  grains  thrice 
daily. 

SCABIES. 
Synonym. — THE  ITCH. 

Scabies  is  a  contagious  parasitic  disease,  due  to  the  acarus  sca- 
beii,  characterized  by  a  multiform  eruption  of  a  peculiar  distrilm- 
tion  and  the  presence  of  cuniculi,  or  burrows,  which,  if  found, 
are  pathognomonic.  The  depredations  are  wrought  by  the 
female,  who  burrows  just  below  the  surface  of  the  skin,  deposits 
feces  and  eggs,  and  there  dwells.  As  soon  as  the  young  are 
hatched  they  start  out  energetically  likewise  to  burrow.  These 
burrows  are  seen  as  zigzag  or  straight  dotted  linear  elevations 
of  the  epidermis,  and  are  found  between  and  on  the  sides  of  the 
fingers  and  on  the  flexure  surface  of  the  wrist ;  also  on  the  penis 
in  males. 

As  the  mite  seeks  warm,  moist,  and  protected  places  for  its 
habitat,  this  disease  therefore  has  its  own  peculiar  distribution, 
viz. — between  the  fingers,  on  the  flexor  surfaces  of  the  wrists, 
anterior  folds  of  the  axillae,  and  on  the  abdomen  and  buttocks. 
Except  in  infants  and  young  children,  the  face  and  scalp  are  free. 

The  diagnosis  is  usually  easily  made  from  the  history  of  con- 
tagion often  given,  the  peculiar  distribution  of  the  dermatitis,  the 
multiformity  of  the  lesions  (burrows,  vesicles,  papules,  pustules, 
scratch-marks,  and  blood  crusts),  the  marked  itching,  especially 
at  night,  and,  except  in  infants,  the  freedom  of  the  scalp  and  face 
from  invasion.  In  children  the  burrows  are  usually  readily 
found,  and  when  seen,  they  are  pathognomonic. 

Treatment. — The  itch  itself  is  not  difficult  to  cure,  but  the 
resulting  eczema  or  dermatitis  may  be  troublesome.  Too  little 
treatment,  on  the  one  hand,  and  too  much  or  too  vigorous,  on 
the  other,  is  to  be  deprecated.  (For  the  dermatitis  resulting  from 
the  irritating  application  see  Eczema  and  its  treatment.) 

The  first  thing  to  do  is  to  give  the  child  a  thorough  bath  in  hot 
water  and  soap,  to  soften  the  epidermis  and  open  up  the  bur- 


7/4  DISEASES    OF    THE    SKIN. 

rows,  and  then  apply  the  following  ointment  every  night  for  four 
nights,  rubbing  in  thoroughly  from  head  to  feet  : 

R.     Sulph.  pnecip., 

Bals.  peruv.,    .............     aa  3J 

Petrolat.,      ................  5J. 

Or: 

JJ.      Beta-naphthol,    .............  3ss~j 

Unguentum  adipis,     ............  3J. 

On  the  next  night  following  the  fourth  application  give  another 
bath,  to  remove  the  ointment,  debris,  etc.  Allow  the  patient  then 
to  go  without  any  applications  for  three  or  four  days,  as  a  der- 
matitis may  have  been  set  up  from  the  irritating  parasiticides. 
This  will  then  subside  in  a  few  days.  The  disease  may  not  have 
been  cured,  or  some  of  the  mites  may  have  escaped  ;  if  so,  a 
second  course  of  treatment  for  four  days  will  almost  certainly 
cure  the  disease. 

In  young  infants  the  remedies  outlined  above  may  be  too  irri- 
tating, hence  styrax  is  to  be  used,  pursued  as  directed  for  the 
older  children  : 


R.     Styracis  liq., 

Ol.  olivse,    ........ 

Sic.  —  Apply  at  night  for  two  or  three  nights. 


SEBORRHEA. 

Seborrhea  is  a  functional  disease  of  the  sebaceous  glands  of 
the  skin,  characterized  by  an  increase  in  the  amount  of  sebum 
poured  out  or  an  alteration  in  its  quality,  in  the  form  of  oily,  scaly, 
or  crusted  material.  There  are  two  varieties,  seborrhcea  oleosa 
and  seborrhcea  sicca. 

Seborrhcea  oleosa  appears  in  the  form  of  a  greasy  coating  on 
the  skin,  most  commonly  on  the  scalp  and  face. 

If  the  vernix  caseosa  of  the  new-born  continues,  it  may  pass 
into  seborrhea,  and  this,  if  neglected,  may  run  into  an  eczema. 
Smegma  of  the  genitals  is  a  form  of  the  same  disorder,  and  if 
excessive  or  unremoved,  it  produces  considerable  discomfort  and 
perhaps  balanoposthitis.  The  treatment  of  seborrhea  is  both 
constitutional  and  local,  those  suffering  from  the  disorder  being 
usually  in  a  depraved  state  of  health.  After  infancy  it  is  most 
likely  to  appear  about  the  time  of  puberty.  Functional  disorders 
should  be  attended  to  and  nutrition  kept  at  a  high  plane.  The 
local  treatment  consists  of  removing  the  scales  and  crusts.  The 
best  application  is  salicylic  acid  1 5  grains,  petrolatum  one  ounce, 


TINEA    TRICHOPHYTINA.  775 

left  on   over  night,  and   then  wash   with   hot  water  and   Castile 
soap. 

Sulphur  is  the  most  reliable  remedy  for  seborrhea — one  dram 
to  one  ounce  of  petrolatum  in  an  ointment  rubbed  into  the  scalp. 
The  German  superfatty  sulphur  salicylic  soaps  form  an  elegant 
mode  of  applying  sulphur  to  the  scalp.  They  can  now  be  had 
in  most  drug  shops. 

The  vegetable  parasitic  diseases  most  commonly  met  with 
in  childhood  are  ringworm  and  tinea  favosa.  Tinea  versicolor 
occurs  so  rarely  that  no  consideration  need  be  taken  of  that 
affection. 

TINEA   TRICHOPHYTINA. 

Synonyms. — TINEA   TRICHOPHYTINA   TONSURANS  ;    RINGWORM    OF 

THE  SCALP. 

Ringworm  occurs  in  the  scalp  up  to  the  age  of  sixteen  ;  after 
that  the  disease  is  practically  unknown  to  infect  this  region. 

Ringworm  occurring  in  the  scalp  is  not  a  trivial  variety,  like 
ringworm  of  the  nonhairy  portion.  It  is  a  stubborn  and  serious 
disease,  frequently  resisting  for  months,  and  sometimes  years, 
the  most  persistent  and  intelligent  treatment. 

The  diagnosis  is  usually  made  without  any  difficulty,  but  we 
have  so  frequently  seen  instances  where  the  treatment  prescribed 
in  new  cases  has  been  poorly  adapted,  or  perhaps  so  improperly 
carried  out  that  these  incipient  cases,  instead  of  being  cured  in 
a  few  weeks  or  months,  have  run  on  from  bad  to  worse  and  lasted 
for  years.  These  children  spread  the  disease  right  and  left,  and 
inoculate  others  in  the  same  family,  institution,  or  school,  or,  per- 
haps, the  whole  neighborhood.  Instead,  had  persistent  and 
vigorous  treatment  been  instituted  and  carried  out  from  the  very 
beginning,  the  disease  would  have,  it  may  be,  been  readily  cured 
in  a  comparatively  short  time  and  have  prevented  the  inoculation 
of  others.  Therefore,  be  it  remembered,  that  no  case  of  ringworm 
of  the  scalp  should  ever  be  slighted  or  made  light  of  to  the 
family  or  attendants. 

Etiology. — The  cause  of  ringworm  is  found  in  the  growth 
and  development  of  a  parasite  or  fungus.  Until  recently  the 
trichophyton  fungus  was  supposed  to  be  the  sole  cause  of  this 
affection.  Sabouraud,  and  others  following  him,  have  differen- 
tiated three  great  varieties,  two  of  which  are  trichophytic,  and  a 
third  a  different  species,  viz. — microsporon  audouinii.  A  full 
description  of  these  several  varieties  may  be  found  in  the  latest 
editions  of  the  dermatologic  works.  The  disease  is  very  con- 


7/6  DISEASES    OF    THE    SKIN. 

tagious,  is  very  common,  and  is  met  with  everywhere.  Ring- 
worm of  the  scalp  is  a  disease  of  childhood,  and  is  seldom  seen 
after  puberty.  The  disease  is  usually  contracted  from  the  lower 
animals,  or  from  child  to  child  through  the  medium  of  hats,  caps, 
brushes,  towels,  wearing  apparel,  etc. 

Symptoms. — Tinea  tonsurans  begins  as  a  small,  scaly,  reddish 
spot,  which  grows  peripherally  from  day  to  day.  The  epidermis, 
the  hair,  and  the  hair  follicles  become  invaded  by  the  fungus 
and  a  patch  forms  on  the  surface,  which  is  rounded  or  irregular 
in  shape,  and  varies  in  size  from  a  pea  to  a  dime  or  to  a  quarter- 
dollar  or  larger.  The  patch  is  circumscribed  and  partially  bald. 
The  hairs  are  lusterless,  dry,  broken  off,  twisted,  bent,  or  fallen 
out.  The  follicles  are  prominent  and  have  a  "  goose-skin  "  or 
"  plucked-fowl  "  appearance.  The  larger  patches  are  pale  or 
grayish  red,  and  distinctly  thickened  and  scaly. 

Itching  is  variable — it  may  or  may  not  be  present. 

Microscopic  Examination. — Select  a  few  hairs  from  the  edge  of 
the  patch — the  lighter  the  color  of  the  hair,  the  more  readily  the 
fungus,  as  a  rule,  may  be  found.  Wash  the  hairs  first  with  ether, 
to  remove  any  oil  or  grease,  place  in  a  watch  crystal,  and  soak 
for  twenty  or  thirty  minutes  in  liquor  potassae,  place  on  a  slide, 
and  gently  press  out  under  a  cover-glass.  Examine  with  200  or 
300  power  diameter ;  the  mycelium  and  spores  are  usually  well 
defined. 

Tinea  Kerion. — This  is  an  inflammatory,  suppurative  form  of 
tinea  tonsurans,  characterized  by  edema,  inflammation  of  a  sub- 
acute  type,  and  exudation  of  a  viscid  yellowish  secretion  from  the 
openings  of  the  hair  follicles.  The  disease  is  deep  seated. 

Tumefaction  may  be  present,  and  the  tumors  be  cherry-  to 
egg-sized.  The  patches  are  tender  and  painful,  and  fluctuation 
is  often  marked.  These  tumors  should  never  be  opened  surgi- 
cally. The  hairs  in  the  follicles  are  loosened  by  suppuration  and 
are  easily  pulled  out,  or  eventually  fall  out.  This  variety  of 
disease  frequently  results  in  a  natural  cure.  Sloughing  never 
occurs.  In  severe  cases  permanent  baldness  may  follow. 

Treatment. — Crocker  says  :  "  There  is  only  one  remedy,  viz. — 
perseverance."  Parents  and  attendants  should  be  made  to  com- 
prehend how  rebellious  this  disease  is  to  treatment.  Children 
with  ringworm  should  not  be  allowed  to  attend  school. 

First,  the  hair  should  be  closely  cut  for  an  inch  around  the 
patch  ;  or,  better  still,  the  head  shaved.  Every  third  or  fourth 
day  pluck  out  with  the  fingers  or  forceps  any  loose  or  diseased 
hairs.  The  numerous  stimulating  parasiticides  should  be  applied 
carefully  to  the  patches  and  for  an  inch  around  the  borders,  and 


TINEA    CIRCINATA.  777 

should  be  thoroughly  rubbed  into  the  tissues,  as  deeply  as  possi- 
ble. If  an  ointment  has  been  used,  first  clean  the  scalp  with  tur- 
pentine to  remove  the  old  grease.  Wash  the  scalp  every  day 
thoroughly  with  ordinary  soap,  or,  better  still,  soft  soap  or  tinc- 
ture of  soft  soap.  The  several  remedies  which  have  done  the 
most  good  in  our  hands  are  :  Ointments  of  precipitated  sulphur, 
one  dram  to  one  ounce  ;  beta-naphthol,  one  dram  to  one  ounce  ; 
tar  ointment,  either  alone  or  combined  with  the  above  ;  corrosive 
sublimate,  I  :  500  in  solution,  or  two  to  four  grains  to  ounce  of 
ointment  where  not  too  large  an  area  is  involved  ;  chrysarobin, 
ten  to  thirty  grains  to  one  ounce  ointment.  Care  should  be 
used  with  this  last  remedy,  as  a  spreading  dermatitis  may  be  set 
up. 

Prognosis. — A  guarded  prognosis  should  always  be  given — 
the  disease  often  proving  rebellious  to  treatment ;  months  often 
are  required  to  effect  a  cure. 


TINEA  CIRCINATA. 
Synonym. — RINGWORM  OF  THE  BODY. 

Ringworm  of  the  nonhairy  surface  as  it  occurs  in  children 
is  very  amenable  to  treatment,  and  may  even  run  its  course, 
terminating  in  spontaneous  recovery.  But  should  the  fungus 
find  its  way  into  the  hair  follicles  of  the  scalp,  as  frequently 
happens,  the  case  is  quite  different.  Usually  the  disease  be- 
gins as  a  small,  reddish,  rounded,  scaly  spot,  growing  from 
day  to  day  by  spreading  at  the  periphery,  and  a  patch  forms 
which  is  more  or  less  circular,  slightly  elevated,  and  inflamed, 
covered  with  grayish,  scanty,  adherent  scales.  The  margins 
are  sharply  defined  against  the  sound  adjacent  skin,  and 
slight  vesication  or  small  papules  may  be  present  on  the  circum- 
ference of  the  patches.  These  patches  tend  to  clear  in  the 
center  and  to  spread  on  the  periphery,  assuming  a  ring  shape  ; 
hence  the  name  "  ringworm."  Several  rings  may  coalesce,  and 
the  patches  may  assume  several  varieties  of  shape,  viz. — oval, 
semicircular,  or  serpiginous.  The  patches  of  ringworm  may 
be  in  size  from  that  of  a  pea  to  that  of  a  half-dollar,  and  in 
color  may  vary  from  pale  to  bright  or  dull  red.  In  children  the 
lesions  are  usually  unsymmetric,  and  the  subjective  symptoms 
slight  or  absent.  Under  the  microscope  the  scrapings  from  a 
patch,  placed  on  a  glass  slide,  adding  a  drop  of  liquor  potassae, 
and  covering  with  thin  glass  and  pressing  down  gently,  will 
usually  reveal  mycelium  and  spores.  Tinea  circinata  may  be 


7/8  DISEASES    OF    THE    SKIN. 

mistaken  for  an  eczema,  but  the  history  of  contagion,  the  course 
and  development  of  the  sharply  marginal  annular,  slightly  scaly 
patches,  tending  to  clear  in  the  center,  and,  finally,  the  micro- 
scopic findings,  will  usually  make  the  diagnosis  clear. 

Treatment. — In  children  local  treatment  alone,  and  remedies 
of  a  simple  character,  as  a  rule,  will  suffice  to  effect  a  cure. 
Wash  the  patches  with  soft  soap  and  water,  afterward  applying 
a  solution  of  sodium  hyposulphite  one  dram,  water  one  fluid- 
ounce  ;  or  corrosive  sublimate,  I  :  1000  solution;  or,  in  oint- 
ment form,  one  to  two  grains  to  one  ounce  of  petrolatum  ;  or 
precipitated  sulphur  ^  dram  to  two  drams  to  one  ounce  of  oint- 
ment of  rose-water. 

As  the  disease  is  superficially  seated,  and  therefore  usually 
readily  cured,  care  should  be  taken  to  select  as  nonirritating  a 
remedy  as  possible,  that  the  skin  in  children  be  not  irritated  too 
much,  as  an  eczematous  condition  may  be  set  up.  Always  ap- 
ply the  remedies  carefully  to  and  around  the  spreading  borders 
of  the  patches. 

TINEA  FAVOSA. 

Tinea  favosa  is  a  contagious  vegetable  parasitic  disease  due  to 
the  achorion  schoenleinii,  characterized  by  discrete  or  confluent, 
splitpea-sized,  circular,  cup-shaped,  pale-yellow,  friable  crusts, 
commonly  perforated  by  a  hair. 

The  seat  of  this  disease  is  usually  in  the  scalp,  although  the 
general  surface  of  the  body  and  the  nails  may  also  be  involved. 
The  disease  is  fortunately  extremely  rare  in  American-born 
children,  but  is  not  uncommon  in  Russian,  Italian,  and  Polish 
children,  and  is  rarely  encountered  in  any  but  the  lower  classes. 
Its  customary  seat  is  the  scalp,  but  other  portions  of  the  skin, 
even  the  mucous  membrane,  may  be  invaded. 

On  the  scalp  the  disease  appears  first  as  a  small,  sulphur- 
yellow  disc,  called  a  "  favus  cup,"  imbedded  in  the  epidermis 
and  seated  about  the  hair  follicles.  They  consist  of  almost  pure 
fungus,  and  these  crusts  are  splitpea-sized,  dry,  friable,  and 
sulphur  yellow  in  color,  unless  the  hue  has  been  masked  by 
extraneous  matter  or  blood  or  pus.  They  are  seated  superficially, 
and  may  be  raised  from  the  underlying  skin.  The  skin  beneath 
is  depressed,  smooth,  shiny,  atrophied,  or  perhaps  suppurating, 
hence  the  disease  leads  to  atrophy  of  the  follicle  and  to  loss  of 
tissue  and  scarring,  permanent  baldness,  therefore,  following  in 
some  cases.  The  hairs  are  invaded  with  the  fungus,  and  are 
dry,  brittle,  and  split.  If  the  disease  is  somewhat  extensive, 
the  peculiar  "  mousey  odor"  may  be  noticeable. 


URTICARIA.  779 

Microscopic  Examination. — Take  some  of  the  crust  and 
examine  the  same  way  as  in  ringworm.  The  mycelium  and 
spores  are  readily  detected. 

The  course  of  the  disease  is  chronic,  often  lasting  years,  and 
relapses  are  common  ;  therefore  a  guarded  prognosis  should  be 
given. 

Treatment. — Remove  the  crusts  aseptically ;  depilate  ;  and 
rub  in  thoroughly  parasiticides,  as  in  tinea  tonsurans.  The 
affected  regions  should  be  washed  frequently.  Sulphur,  beta- 
naphthol,  mercurials,  should  be  applied  very  much  as  in  tinea 
tonsurans. 

URTICARIA. 
Synonyms. — HIVES  ;  NETTLE-RASH. 

Urticaria  is  an  inflammatory  disease  of  the  skin,  characterized 
by  the  development  of  wheals,  which  are  of  various  sizes  and 
shapes,  fugitive  and  ephemeral  in  character,  white  or  reddish, 
accompanied  by  painful  pricking  and  tingling  sensations,  and 
usually  slightly  elevated  above  the  skin.  On  the  face  it  may 
produce  great  disfigurement  :  a  single  part,  as  the  lip,  may  be- 
come enormous.  The  disturbances  of  sensation  may  be  merely 
annoying  or  overwhelmingly  painful.  The  name  "  nettle-rash  " 
alludes  to  its  similarity  to  the  sting  of  a  nettle.  The  lesions 
may  appear  in  almost  any  part  of  the  body  and  shift  about  con- 
stantly. If  the  disease  attacks  the  epiglottis,  it  may  threaten 
life.  The  duration  depends  upon  the  persistence  of  the  cause. 
The  forms  of  urticaria  are  the  papular,  hemorrhagic,  bullous,  or 
urticaria  tuberosa,  or  giant  urticaria.  It  may  become  chronic,  the 
lesions  coming  and  going  in  repeated  crops.  The  causes  of 
urticaria  are  many  and  diverse — external  irritants,  as  the  stings  of 
insects  and  jelly-fish,  and  internal  causes,  the  secondary  effects 
of  intestinal  derangement.  Certain  articles  of  food  produce  it 
in  those  predisposed,  especially  shell-fish,  the  sea  scavengers, 
such  as  lobsters  and  crabs,  which  frequently  contain  unusually 
severe  poisons  acquired  from  the  carrion  on  which  they  feed. 
Some  berries  produce  it  in  the  susceptible.  Exciting  causes  may 
be  sudden  emotion  or  excitement.  The  treatment  depends 
chiefly  on  the  discovery  and  removal  of  the  cause  ;  some  sus- 
ceptible individuals  have  the  disease  developed  within  a  very  few 
minutes  after  tasting  certain  articles  of  food.  We  know  a  child, 
now  twelve  years  old,  who  for  years  has  been  so  sensitive  to 
any  portion  of  egg  that  to  taste  an  article  which  contains  this 
will  produce,  in  a  very  few  minutes,  swollen  lips  and  throat,  and 


780  DISEASES    OF    THE    SKIN. 

if  any  considerable  amount  be  swallowed,  hives  will  develop  in 
less  than  an  hour.  In  certain  cases  of  suspected  poisoning  it  is 
wise  to  administer  an  emetic  ;  in  all  cases  it  is  better  to  give  a 
purge.  A  saline  laxative  is  best,  as  being  quickest,  but  it  is  well 
to  follow  this  by  some  thorough  cleansing  agent,  as  castor  oil. 
Then  the  intestines  require  critical  and  deliberate  attention. 
Diuretics  are  often  of  use ;  the  alkaline  mineral  waters  and  vari- 
ous sorts  of  eliminants  and  intestinal  antiseptics  ;  pilocarpin  by 
mouth  or  under  the  skin  is  of  value.  Quinin  is  admitted  by  all 
to  be  a  useful  remedy,  for  known  or  unknown  reasons.  Arsenic 
is  often  of  service  when  all  other  remedies  fail.  Codein  is  an 
excellent  quieting  agent.  Externally,  alkaline  baths  are  of  great 
comfort,  followed  by  soothing  powders.  Vinegar  and  water, 
alcohol  and  water,  and  carbolic  acid  and  glycerin  lotions  relieve. 
Chloroform,  a  dram  to  the  ounce  of  alcohol ;  ammonia  and 
water,  especially  bran  water,  each  have  their  sphere.  In  the  sub- 
acute  or  chronic  forms  ointments  act  happily.  (See  the  treat- 
ment for  Eczema.) 


CHAPTER  XVII. 

DISEASES  OF  THE  EAR. 


The  more  common  diseases  of  the  ear  occurring  in  childhood 
will  be  described,  and,  for  the  better  convenience  of  the  busy 
practitioner,  only  such  treatment  as  has  proved  most  efficient  in 
our  hands  will  be  given.  The  diseases  requiring  instruments  of 
precision  for  their  diagnosis  and  belonging  essentially  to  the  ex- 
pert will  not  be  dealt  with. 

Before  considering  the  various  forms  of  affections  of  the  ear  it 
may  be  well  to  recall  a  few  facts  of  special  interest  in  the  anat- 
omy of  the  ear  in  early  life.  The  ear  of  the  child,  like  that  of 
the  adult,  is  divided  into — (i)  The  sound-conducting  apparatus, 
which  includes  (tf)  the  external  ear,  auricle,  and  external  meatus  ; 
(£)  the  middle  ear  (the  tympanic  cavity  with  membrana  tympani 
and  ossicula,  the  Eustachian  tube,  and  the  cup-shaped  cavity 
which  is  the  precursor  of  the  mastoid  cells.  (2)  The  sound- 
perceiving  apparatus — the  internal  ear  or  labyrinth. 

The  external  meatus  of  the  infant  is  nearly  as  deep  as  that  of 
the  adult ;  absence  of  the  bony  canal  at  this  stage  is  compen- 
sated by  the  presence  of  the  fibrous  membrane  in  which  the  bone 
is  formed  later.  The  caliber  of  the  meatus  is  smaller  in  infancy 
and  more  than  apt  to  be  prolapsed,  while  its  direction  in  the  very 
young  is  often  at  first  downward  instead  of  upward.  It  is  there- 
fore often  necessary,  in  order  to  obtain  a  good  view  of  the 
fund  us,  to  draw  the  auricle  downward  and  outward,  and  not  up- 
ward and  backward  as  is  the  case  in  the  adult  ear  or  in  that  of 
later  childhood.  It  may  be  well  also  to  remember  that  the  drop- 
ping of  the  lower  jaw  will  sometimes  enlarge  the  meatus. 

The  lining  of  the  middle  ear  is  continuous,  through  the  Eu- 
stachian tube,  with  that  of  the  nasopharynx,  and  therefore 
diseases  of  the  vault  of  the  pharynx,  whether  primary  or  sec- 
ondary, are  apt  to  be  accompanied  by  ear  symptoms.  Among 
the  anatomic  factors  which  make  diseases  of  the  middle  ear  an 
especial  menace  in  childhood  is  the  suture  (sutura  petroso  squa- 
mosa)  which  is  found  in  the  roof  of  the  middle  ear  at  this  age, 
and  which  sometimes  amounts  to  a  dehiscence  which  persists 

781 


782  DISEASES    OF    THE    EAR. 

throughout  life.  In  the  new-born  infant  processes  of  connective 
tissue  from  the  dura  containing  blood-vessels  pass  through  this 
suture  into  the  tympanic  cavity.  It  may  thus  be  readily  seen 
why  a  hyperemia  of  the  tympanic  mucous  membrane  would 
promptly  spread  to  the  dura  and  cause  the  meningeal  irritation 
which  is  so  often  met  with  in  middle-ear  diseases  in  children. 
The  fetal  tympanic  cavity  is  filled  with  a  gelatinous  mass,  some 
of  which  persists  partially  degenerated  after  birth  as  a  yellowish- 
green,  thick  fluid  containing  fat  and  pus-corpuscles,  which  are 
usually  absorbed  a  few  weeks  after  birth,  but  which  at  times 
causes  an  inflammation  of  the  tympanum  and  leads  to  the  per- 
foration of  Shrapnell's  membrane,  which  has  been  named  the 
foramen  of  Rivinus.  The  lining  of  the  tympanum  in  the  new- 
born infant  is  remarkable  for  the  abundance  of  its  vessels  and 
its  general  tumefaction.  The  mastoid  antrum  is  the  only  one 
of  the  air-spaces  present  in  the  new-born. 

The  ears  of  children  should  be  carefully  examined  during  the 
progress  of  the  exanthemata  and  infectious  diseases,  and  in  cases 
of  fever  where  the  diagnosis  is  doubtful,  on  account  of  the 
liability  of  throat  affections  to  spread  through  the  Eustachian 
tube  to  the  middle  ear.  In  these  cases  the  onset  of,  the  disease 
is  apt  to  be  insidious,  and  unless  looked  for,  may  not  be  discov- 
ered until  it  has  gone  so  far  as  to  cause  permanent  disability. 
The  habit  of  treating  lightly  the  affections  of  the  ear  in  child- 
hood is  to  be  deprecated.  The  importance  of  their  early  diag- 
nosis and  prompt  treatment  is  realized  when  we  consider  that 
fully  two-thirds  of  the  ear  cases  which  present  themselves  for 
treatment  in  adult  life  originate  in  childhood,  and  a  large  propor- 
tion of  them  might  have  been  cleared  up  by  a  few  simple  treat- 
ments in  their  early  stages. 

Many  people,  including  all  classes  and  conditions,  are  apt  to 
treat  the  ear  diseases  of  childhood  lightly,  an  idea  which  is 
encouraged  by  some  physicians.  Death  has  occurred  in  such 
cases  from  meningitis  when  the  seriousness  of  the  ear  trouble 
was  entirely  unsuspected.  Indeed,  ear  affections  are  the  most 
common  cause  of  leptomeningitis.  Among  the  diseases  which 
show  a  special  predilection  for  ear  involvement  are  scarlet  fever, 
measles,  diphtheria,  typhoid  fever,  influenza,  and  syphilis. 

The  only  instruments  required  for  an  examination  of  the 
fundus  are  a  head  mirror,  a  strong  light,  a  delicate  cotton-tipped 
probe,  and  possibly  a  speculum. 

The  ear  troubles  which  occur  in  childhood  may  be  classified 
as  :  I.  Diseases  of  the  external  ear.  II.  Diseases  of  the  middle 
ear.  III.  Diseases  of  the  internal  ear. 


DISEASES    OF    THE    EXTERNAL    EAR.  783 

I.   DISEASES  OF  THE   EXTERNAL   EAR. 

The  diseases  of  the  skin  which  occur  in  the  external  ear  may 
be  of  almost  any  variety  and  should  be  treated  by  the  same 
means  which  are  used  in  similar  diseases  occurring  elsewhere. 

Eczema  of  the  auricle  and  vicinity  is  the  most  common  of 
the  skin  diseases  met  with  in  this  locality.  It  is  most  often 
caused  by  excoriating  discharges  from  the  middle  ear,  and  will 
usually  promptly  yield  to  treatment  after  removal  of  the  cause. 

Treatment. — In  obstinate  chronic  cases  the  crust  should  be 
carefully  removed  and  the  surface  cleaned  prior  to  the  applica- 
tion of  healing  remedies.  For  this  purpose  green  or  Castile 
soap  and  water  or,  better,  peroxid  of  hydrogen  may  be  used  to 
soak  the  scab,  after  which  it  can  be  readily  removed  ;  then  the 
surface  may  be  dried  by  a  solution  of  nitrate  of  silver  (sixty 
grains  to  the  ounce  of  water),  after  which  an  ointment  of  the 
yellow  oxid  of  mercury  (two  grains  to  the  dram  of  petrolatum) 
should  be  carefully  rubbed  into  the  excoriated  surface.  In  cer- 
tain cases,  after  the  cleaning  process,  calomel  ointment,  twenty 
grains  to  one  ounce  of  petrolatum,  or  an  ointment  of  zinc  oxid, 
preceded  by  black  wash,  or  ichthyol  ointment,  25  per  cent.,  may 
be  successfully  used,  but  most  cases  yield  sooner  or  later  to  the 
treatment  first  outlined.  Most  of  these  cases  of  eczema  are 
essentially  local  in  character,  but  in  some  of  them  cod-liver  oil, 
hypophosphites,  and,  in  the  noninflammatory  type,  arsenic  may 
be  indicated. 

Furuncles  or  boils  occur  less  frequently  in  children  than  in 
adults.  The  exciting  cause  is  probably  the  staphylococcus 
pyogenes  aureus  and  albus,  which  penetrate  the  hair  follicles,  and 
which  are  introduced  by  mechanical  irritants,  foreign  bodies,  the 
instillations  of  irritating  substances,  and  the  like.  They  fre- 
quently occur  in  one  otherwise  in  apparently  good  health.  They 
are  usually  situated  near  the  orifice  of  the  external  meatus,  in  the 
cartilaginous  portion.  Their  most  prominent  symptom  is  pain, 
which  is  most  intense  when  they  are  deep  seated,  radiating  over 
the  whole  side  of  the  head  and  neck.  When  not  deep  seated, 
swelling  may  usually  be  easily  detected  by  the  aid  of  a  reflected 
light.  This  is  at  times  red  or  livid,  and  is  very  painful  to  the 
touch  of  the  cotton -tipped  probe.  If  deep  seated,  the  pain  is 
more  marked,  the  swelling  less  so,  and  there  is  usually  no  change 
of  color.  Their  location,  however,  may  be  determined  by  the 
aid  of  the  probe.  If  anteriorly  located,  the  region  in  front  of 
the  tragus  may  be  swollen  and  tender,  and  when  posteriorly 
located,  they  may  simulate  mastoid  swelling  and  pain.  Two 


784  DISEASES    OF    THE    EAR. 

conditions  which  resemble  furuncles  in  appearance  are  :  (i)  Exos- 
toses,  when  covered  by  a  red  skin ;  (2)  bulging  caused  by 
burrowing  pus  from  the  mastoid  or  tympanum. 

Treatment. — The  severe  pain  of  furuncles  is  most  promptly 
relieved  by  a  deep  incision  through  the  tender  area,  which  should 
be  done  with  strict  asepsis.  The  release  of  the  tension  conse- 
quent to  the  blood-letting  will  usually  bring  relief,  even  if  no  pus 
be  liberated.  The  incision  should  be  anointed  with  the  official 
ointment  of  the  yellow  oxid  of  mercury,  which  should  be  gently 
forced  into  the  wound.  Should  the  furuncle  be  pointed,  a  small 
prick  will  probably  bring  relief  without  the  prick  itself  causing 
any  pain.  The  incision  should  be  made  under  strong  illumina- 
tion, with  strict  asepsis,  and  preferably  with  a  small  knife  made 
for  this  purpose.  If  the  pain  is  not  excessive,  hot  boric  solution 
may  be  gently  syringed  into  the  ear  or  allowed  to  flow  in  from 
a  fountain  syringe  at  a  slight  elevation  or  from  a  teapot.  Hot- 
water  bags  or  hot  salt-  or  hop-bags  often  give  relief,  after  careful 
cleansing  and  the  application  of  an  ointment  of  ichthyol  or  the 
yellow  oxid  of  mercury.  So,  also,  hot  carbolized  oil  or  carbol- 
ized  glycerin  is  at  times  grateful.  The  use  of  sweet  oil  and 
laudanum,  hot  raisins,  tobacco-juice,  and  what  not  through  the 
whole  gamut  of  "household  remedies"  should  be  discouraged. 
Furuncles  often  occur  in  series  of  three  or  four,  and  it  is  well 
to  forewarn  those  interested  of  this  fact. 

Ceruminosis. — Excess  of  cerumen  or  wax  banked  up  in  the 
external  meatus  may  be  caused  by  :  (i)  frequent  hyperemias  of 
this  region  ;  (2)  contraction  of  the  meatus  ;  (3)  improper  clean- 
ing of  the  external  meatus  by  inserting  the  twisted  corner  of  a 
wash-rag  or  towel  or  similar  contrivance  into  the  ear. 

Parents  and  nurses  should  be  especially  warned  against  me- 
chanically irritating  the  lining  of  the  canal  by  undue  cleanliness, 
and  it  should  be  pointed  out  to  them  that  if  the  concha  be  wiped 
out  with  a  soft  moist  rag,  the  canal  will  take  care  of  itself,  and 
that  anything  introduced  into  the  meatus  is  likely  to  do  harm 
and  result  in  anything  but  the  desired  cleanliness.  These  plugs 
of  epithelium  and  wax  may  be  soft  and  yellowish,  or  hard  and 
dark  brown.  They  can  be  readily  detected  by  the  aid  of  reflected 
light,  and  may  be  safely  and  promptly  removed  by  syringing 
with  hot  water. 

Treatment. — The  canal  should  be  straightened  and  opened  by 
tension  on  the  auricle,  and  a  stream  of  hot  water  from  a  syringe 
should  be  directed  around  the  edge  of  the  plug  parallel  to  the  direc- 
tion of  the  canal  and  chiefly  along  the  upper  wall.  A  few  syringe- 
fuls  carefully  directed  will  bring  out  the  plug  without  further 


DISEASES    OF    THE    MIDDLE    EAR.  785 

manipulation.  Should  the  mass  be  too  hard,  however,  it  may  be 
softened  by  a  few  drops  of  water  and  bicarbonate  of  soda,  added 
at  intervals  for  twenty-four  hours,  after  which  it  may  easily  be 
removed  by  syringing.  Instruments  should  not  be  used  forcibly 
for  the  removal  of  wax.  The  wax  plug  itself  is  practically  innoc- 
uous, while  clumsy  instrumentation  will  bring  about  grave  dis- 
turbances. After  the  removal  of  the  wax  the  canal  should  be 
gently  wiped  out  with  cotton  soaked  in  equal  parts  of  peroxid 
of  hydrogen  and  alcohol,  then  loosely  plugged  with  aseptic 
cotton,  and  the  directions  given  that  it  should  be  removed  at 
bedtime  and  left  out. 

Foreign  Bodies  in  the  Ear. — These  may  be  of  any  kind  or 
shape,  and  may  readily  be  detected  by  the  use  of  strong  reflected 
light.  The  symptoms  are  not  usually  serious,  even  when  the 
foreign  substance  is  allowed  to  remain  in  the  ear  over  long 
periods  of  time.  Cases  have  been  reported  in  which  beads, 
grains  of  wheat,  and  like  substances  have  remained  in  the  ear  for 
forty  to  forty-five  years  only  to  be  discovered  by  chance  at  the 
end  of  that  time.  This  point  should  be  especially  borne  in  mind, 
as  it  is  better  to  allow  the  foreign  body  to  remain  in  the  ear  than 
to  use  severe  measures  for  its  extraction. 

Treatment. — The  size  and  shape  of  the  foreign  body,  as  well 
as  its  location,  should  be  noted  by  the  aid  of  reflected  light ;  then, 
with  a  carefully  directed  stream  of  tepid  water  or  boric  acid  solu- 
tion, the  body  may  be  forced  out  of  the  canal.  The  syringe 
nozle  should  be  long  and  narrow,  so  that  the  course  of  the  stream 
may  be  accurately  followed  by  the  eye,  and  it  should  be  so 
directed  that  it  will  pass  the  body,  which  will  then  be  forced  out 
by  its  return  flow.  This  failing  in  the  hands  of  one  unskilled  in 
ear  manipulation,  it  would  be  well  to  refer  the  case  to  an  expert. 
Clumsy  manipulations  of  foreign  bodies  have  brought  about  most 
disastrous  results. 

II.  DISEASES  OF  THE  MIDDLE  EAR. 

The  majority  of  diseases  of  the  ear  occurring  in  childhood 
come  under  this  heading,  and  they  may  be  intelligently  studied 
under  four  divisions — namely:  (i)  Acute  inflammation  of  the 
middle  ear  ;  (2)  acute  suppurative  inflammation  of  the  middle  ear  ; 
(3)  chronic  suppurative  inflammation  of  the  middle  ear  ;  (4) 
chronic  catarrhal  (sclerotic)  inflammation  of  the  middle  ear. 

i.  Acute  inflammation  of  the  middle  ear  (otitis  media 
acuta)  and  acute  suppurative  inflammation  of  the  middle  ear 
resemble  each  other  up  to  a  certain  point  in  etiology,  symptoms, 
50 


786  DISEASES    OF    THE    EAR. 

course,  and  treatment.  They  may,  therefore,  be  considered 
together.  Each  may  be  defined  as  an  acute  inflammation  of  the 
lining  membrane  of  the  middle  ear,  caused  by  undue  exposure, 
inflammation  of  the  nasopharynx,  foreign  bodies,  or  other  trau- 
matisms.  It  may  at  times  be  superimposed  upon  a  chronic 
middle-ear  catarrh.  Both  the  simple  and  suppurative  forms  are 
more  common  in  children  than  in  adults.  Usually  but  one  ear 
is  affected  at  a  time,  although  in  cases  of  scarlatina  or  typhoid 
fever  both  ears  are  often  affected.  The  two  forms  resemble  each 
other  up  to  the  point  of  perforation  of  the  membrana  tympani, 
which  determines  the  suppurative  condition.  In  the  suppurative 
condition,  however,  the  symptoms  are  apt  to  be  more  aggra- 
vated. Scarlet  fever  is  a  most  fertile  source  of  middle-ear  in- 
flammation. Twenty  per  cent,  of  all  chronic  diseases  of  the 
middle  ear  originate  in  this  disease.  The  onset  of  the  ear  trouble 
in  scarlet  fever  is  often  insidious,  and  unless  the  ear  is  examined, 
even  when  there  are  no  symptoms  present,  its  course  may  be 
partly  run  and  irreparable  damage  done  before  detection.  It  is 
interesting  to  note  in  this  connection  that  the  ear  symptoms  in 
scarlet  fever  are  closely  associated  with  the  nephritis,  and  it  has 
been  held  that  the  early  cure  of  the  kidney  condition  has  a  happy 
effect  on  the  course  of  the  ear  trouble,  and  vice  versa.  Special 
examination  of  the  ear  should  be  made  from  time  to  time  as  a 
routine  procedure  in  scarlet  fever;  odor  and  discharge  should  be 
carefully  looked  for  so  that  the  danger  of  infection  of  the  men- 
inges  may  be  guarded  against.  The  ear  is  less  frequently  af- 
fected in  measles  than  in  scarlatina.  Here,  again,  the  ear  trouble 
is  the  result  of  extension  of  the  inflammation  from  the  throat 
through  the  Eustachian  tube.  In  measles  the  otitis  is  apt  to  be 
of  milder  form  than  in  scarlet  fever,  but  it  should,  nevertheless, 
be  carefully  looked  to.  In  hereditary  syphilis  inflammation  may 
spread  through  the  Eustachian  tube  to  the  middle  ear.  In 
rheumatoid  arthritis  ankylosis  of  the  ossicula  may  rarely  occur  in 
childhood,  while  in  Hodgkin's  disease  deafness  may  occur  from 
occlusion  of  the  Eustachian  orifices  by  adenoid  enlargement. 
Ear  diseases  may  be  early  manifested  in  leukemia. 

Symptoms. — There  may  be  no  early  symptoms  or  there  may 
be  a  stinging,  throbbing  pain  extending  at  times  over  the  head  to 
the  teeth,  usually  intermitting  and  worse  at  night.  In  children 
there  is  frequently  a  tenderness  over  the  whole  external  region 
of  the  ear,  more  especially  over  the  region  of  the  Eustachian  tube 
in  the  neck.  In  the  very  young  ear  pains  are  frequently  indi- 
cated by  the  patient  putting  the  hand  to  the  affected  ear,  or  lean- 
ing toward  the  affected  side  ;  also  by  restlessness  and  irritability. 


DISEASES    OF    THE    MIDDLE    EAR.  787 

There  may  or  may  not  be  fever,  although  in  the  suppurative  form 
there  is  apt  to  be  a  rise  of  temperature.  Older  children  may 
complain  of  noises  or  numbness  in  the  head  and  of  difficulty  in 
hearing.  Examination  of  the  fundus  in  this  condition  discloses 
the  membrana  tympani  more  or  less  injected,  especially  in  the 
region  of  the  short  process  and  manubrium. 

2.  Acute  Suppurative  Inflammation  of  the  Middle  Ear. — 
In  the  more  severe  forms  (suppurative  forms),  which  lead  to  per- 
foration, the  entire  membrana  tympani  is  injected  as  well  as  the 
osseous  meatus,  so  that  it  is  difficult  to  tell  the  membrana  tym- 
pani from  the  walls  of  the  canal,  as  the  boundaries  are  no  longer 
well  defined  and  the  perspective  lost,  while  the  cartilaginous 
meatus  is  often  painfully  swollen,  as  well  as  the  external  parts 
.and  the  neighboring  glands.  A  perforation,  when  present,  is 
difficult  to  be  seen  even  by  the  expert.  However,  its  presence 
may  be  recognized  by  the  discharge  and  cessation  of  the  severe 
pain.  The  results  of  middle-ear  inflammation  are  :  («)  Healing  ; 
(^)  transition  to  the  chronic  form  ;  (c)  progression  to  the  suppu- 
rative form,  mastoiditis,  meningitis,  or  sinus  phlebitis. 

Prognosis. — Generally  favorable,  except  in  the  infectious  cases 
or  in  weaklings. 

Treatment. — This  should  first  be  directed  to  the  nasophar- 
yngeal  condition.  The  nasopharynx  should  be  thoroughly 
.sprayed  with  an  alkaline  antiseptic  solution.  The  Politzer  bag 
tip  should  then  be  applied  to  one  nostril,  and  the  bag  forcibly 
compressed  so  as  to  blow  any  remaining  secretions  out  of  the 
opposite  nostril.  The  nasopharynx  should  then  be  wiped  with 
a  curved  cotton-tipped  applicator,  which  has  been  previously 
dipped  in  boroglycerid  or  dilute  glycerol  of  tannin,  and  intro- 
duced through  the  mouth  back  of  the  soft  palate.  The  Eusta- 
chian  orifices  should  receive  special  attention  in  this  cleansing 
process.  The  Politzer  bag  tip  should  then  be  applied  to  one 
nostril,  the  other  firmly  compressed,  and  the  vapor  of  chloro- 
form or  iodin  or  simply  heated  air  from  above  a  lamp  should  be 
gently  forced  into  the  middle  ear.  In  order  to  maintain  suffi- 
cient pressure  in  the  nasopharynx  to  successfully  Politzerize  the 
tympanum,  the  soft  palate  should  be  raised  against  the  posterior 
pharyngeal  wall,  to  accomplish  which  the  patient  should  be  told 
to  puff  out  the  cheeks  or  swallow  a  sip  of  water.  If  water  is 
used,  the  bag  should  be  compressed  at  the  moment  the  pomum 
Adami  rises.  The  act  of  crying  will  also  serve  to  raise  the  soft 
palate.  During  the  early  stages  this  line  of  treatment  will  often 
immediately  relieve  earaches  as  well  as  deafness.  This  failing,  a 
hot-water  bag  should  be  applied  to  the  ear  or  a  hot  douche  of 


788  DISEASES    OF    THE    EAR. 

water  or  boric  acid  solution,  long  continued,  may  be  used  with 
gentleness.  The  various  household  remedies  so  often  indulged 
in  should  be  adjured.  They  embrace  poultices,  onion-cores, 
sweet  oil,  hot  raisins,  laudanum,  the  painting  of  the  mastoid  with 
tincture  of  iodin,  or  even  blistering  it.  Poultices  tend  to  increase 
the  congestion  ;  onions  are  surgically  unclean  ;  iodin  and  blister- 
ing disguise  mastoid  complications  which  may  arise  later.  If  the 
symptoms  are  severe,  indicating  that  we  have  to  deal  with  the 
suppurative  form,  a  paracentesis  will  give  relief  when  there  is 
bulging  of  the  membrane.  This  little  operation  should  be  done 
under  strict  asepsis  and  strong  illumination.  The  most  promi- 
nent point  should  be  incised,  care  being  taken  to  avoid  the  ossi- 
cles and  due  account  being  taken  of  the  obliquity  of  the  tympanic 
membrane.  Injuries  of  the  promontory  are  not  apt  to  retard 
the  healing  process.  The  incision  should  be  followed  with  infla- 
tion by  the  Politzer  bag,  as  described  above,  and  a  hot  douche, 
or  syringing  with  hot  water  or  boric  acid  solution,  after  which 
the  canal  should  be  dried  and  protected  with  aseptic  cotton. 
Daily  cleansing  and  Politzerizing  should  follow  until  suppuration 
ceases.  Due  attention  should  be  paid  to  the  general  condition, 
and  the  indications  met  as  in  ordinary  cases.  The  patient  should 
be  kept  in  a  recumbent  position.  Should  the  mastoid  region 
become  puffy,  boggy,  red,  and  tender,  with  intermitting  fever, 
and  especially  if  these  symptoms  are  accompanied  with  puffiness 
of  the  superior,  posterior,  inner  wall  of  the  meatus,  opening  of 
the  mastoid  is  indicated.  Sudden  cessation  of  the  discharge  with 
a  drop  of  temperature  and  slowing  of  the  pulse  imply  that  the 
pus  has  made  into  the  cranial  cavity. 

3.  Chronic  suppurative  inflammation  of  the  middle  ear 
may  be  defined  as  a  suppurative  condition  of  the  middle  ear 
occurring  most  frequently  in  childhood,  and  involving  the  tym- 
panic membrane  and  often  the  external  meatus,  the  bony  walls  of 
the  middle  ear,  or  even  the  labyrinth. 

Causes. — The  more  common  cause  is  the  progression  of  the 
acute  purulent  otitis  of  childhood,  especially  that  following  scarlet 
fever,  diphtheria,  typhoid  fever,  and  other  infectious  exanthema- 
tous  diseases.  It  is  frequently  bilateral.  It  may  at  times  de- 
velop in  certain  cachexiae  without  the  previous  acute  phenomena. 

Symptoms  and  Results. — These  are  most  various  and  compli- 
cated. It  will  be  sufficient  for  our  purpose  to  state  these  in 
a  general  way  only,  leaving  the  details  to  text-books  devoted 
especially  to  diseases  of  the  ear.  In  the  very  young  attention  is 
frequently  first  called  to  this  disease  by  the  discharge  from  the 
meatus  or  by  the  odor.  Headaches  or  fullness  in  the  head  may 


DISEASES    OF    THE    MIDDLE    EAR.  789 

be  present,  or  more  rarely  giddiness  or  vomiting  ;  disturbances 
of  hearing,  in  varying  degrees,  are  usually  present,  and  should 
there  be  damming  up  of  the  pus,  pain  is  also  experienced.  The 
results  of  this  disease  are:  (i)  Hypertrophy  of  the  mucous 
membrane  ;  (2)  hyperplasia  in  the  form  of  granulations  or  polypi 
in  the  tympanic  cavity  ;  (3)  connective-tissue  formation  leading 
to  adhesion  between  the  ossicula,  membrana  tympani,  and  walls 
of  the  tympanum  ;  (4)  destruction  of  the  mucous  membrane, 
membrana  tympani,  and,  often,  of  the  bony  parts.  The  tympanic 
membrane  is  almost  always  perforated  and  it  may  be  thickened. 
The  perforation  may  be  of  any  degree  or  shape.  There  may  be 
caries  or  necrosis  of  the  temporal  bone  or  the  formation  of 
osteophytes.  The  secretion  may  vary  in  character  and  quantity, 
and  the  presence  or  absence  of  odor  is  not  significant  except  as 
indicating  the  retention  of  secretion.  There  may  be  changes  in 
the  secretion  of  cerumen  or  cholesteatomata  may  be  formed. 

Treatment. — While  the  treatment  varies  according  to  the 
character  and  extent  of  the  destruction  of  the  parts,  it  may  be 
outlined  in  a  general  way.  As  in  the  acute  form,  the  naso- 
pharynx should  be  cleansed  and  the  tube-mouths  wiped  out ;  then 
the  ear  should  be  gently  wiped  and  dried  by  a  tuft  of  aseptic 
cotton  on  a  delicate  applicator,  following  which  a  similar  tuft 
dipped  in  peroxid  of  hydrogen  may  be  gently  wiped  over  the 
surface  to  boil  loose  particles  of  dry  mucopus,  epithelial  scales, 
bony  detritus,  and  so  forth.  The  middle  ear  should  be  Politzer- 
ized  to  clear  the  Eustachian  tube,  and  again  wiped  clean.  If 
there  is  tumefaction  of  the  mucous  membrane,  a  solution  of 
alcohol  (50  per  cent,  at  first,  gradually  increased  to  95  per  cent.) 
may  be  applied  to  it,  and  then  again  one  should  Politzerize,  wipe 
dry,  and  dust  with  a  small  amount  of  boric  acid  by  means  of  an 
insufflator.  If  these  cases  prove  obstinate,  aqueous  solutions  of 
silver  nitrate  (sixty  grains  to  the  ounce)  may  be  substituted  for  the 
alcohol  solution,  or  a  solution  of  sulphate  of  zinc  (4  per  cent.),  or 
a  solution  composed  of  alum  (one  dram),  zinc  sulphate  (one  dram), 
carbolic  acid  (forty  grains),  water  (two  ounces).  If  polypi  are 
present,  they  should  be  snared,  or  they  may  be  reduced  by  alcohol 
or  chromic  acid  applications.  Caries  may  indicate  curetment  or  the 
removal  of  the  ossicles,  or  even  one  of  the  various  mastoid  opera- 
tions. At  times  the  cleansing  process  may  be  aided  by  the  use 
of  a  rarefacteur  to  draw  the  pus  into  the  external  meatus,  or  the 
Eustachian  catheter  maybe  needed  the  more  forcibly  to  clear  the 
tube  or  to  guide  various  fluids — e.  g.,  boric  acid  solution  (4  per 
cent.)  and  warm  saline  solution — through  it.  Aristol,  iodo- 
form,  acetanilid,  or  their  modifications  may  be  substituted  for  the 


79O  DISEASES    OF   THE    EAR. 

boric  powder.  These  cases  should  be  cleansed  every  other  day 
at  first,  and  then,  as  they  improve,  twice  weekly,  once  weekly, 
and  so  on,  gradually  increasing  the  intervals  between  treatments 
as  recovery  progresses.  Internal  treatment  is  indicated  in 
rheumatism,  syphilis,  anemia,  and  other  general  diseases.  Chol- 
esteatomatous  masses  may  be  removed  by  means  of  the  curet  or 
attic  syringe,  or  may  require  a  mastoid  operation. 

4.  Chronic  Catarrhal  (Adhesive)  Inflammation  of  the 
Middle  Ear. — This  name  has  been  given  to  those  inflammations 
of  the  middle  ear  which  give  rise  to  sclerotic  (adhesive)  changes 
in  its  lining  mucous  membrane  and  lead  to  permanent  defects  of 
hearing.  The  condition  may  start  in  an  exudative  catarrh,  or 
it  may  start  insidiously  as  an  interstitial  inflammation  which  is 
progressive.  The  condition,  after  running  an  insidious  course, 
usually  ends  in  extreme  hardness  of  hearing.  Fortunately, 
this  disease  is  not  frequent  in  children,  although  its  occurrence 
in  after  life  may  be  precluded  by  the  careful  and  timely  treatment 
of  the  exudative  forms  of  middle-ear  trouble. 

Causes. — (i)  Chronic  nasopharyngeal  catarrh  ;  (2)  postdiph- 
theric  paralysis  ;  (3)  scrofula,  tuberculosis,  marasmus,  or  anemia. 

Pathology. — The  pathologic  changes  consist  in  the  formation 
of  fibrous  connective  tissue  in  the  mucous  membrane,  with 
shrinking  (sclerosis),  atrophy,  and  calcification  of  the  newly 
formed  tissue.  Thus,  the  ossicles  are  bound  to  each  other  and 
to  the  walls  of  the  tympanic  cavity.  The  tympanic  membrane 
may  appear  normal,  may  be  thickened  or  atrophied,  or  may  have 
chalk  deposits  within  it.  The  symptoms  to  be  looked  for  in 
children  are  progressive  deafness,  subjective  noises,  which  latter, 
however,  rarely  annoy  them,  even  when  present,  and  there  may 
be  mental  dullness,  which  may  be  the  most  prominent  symptom. 

Treatment. — Hygienic  conditions  should  be  carefully  attended 
to,  wet  feet  guarded  against,  as  well  as  sudden  cooling  of  the 
body,  and  cold  sleeping-rooms  should  be  avoided.  The  nose 
and  nasopharynx  should  be  placed  in  approximately  normal  con- 
dition by  the  removal  of  deformities,  polypi,  etc.  Politzer's 
method  or  the  catheter  should  be  used  to  inject  air,  chloroform 
vapor,  iodin  vapor,  or  various  solutions  (?)  into  the  middle  ear. 
Gentle  aural  massage  by  means  of  Siegle's  or  Delstanche's  ap- 
paratus is  often  indicated.  The  use  of  the  Valsalva  method  is 
not  advised,  although  automassage  by  pressing  the  finger  to  the 
tragus  may  be  encouraged. 


DISEASES    OF    THE    INTERNAL    EAR.  79! 

III.  DISEASES  OF  THE  INTERNAL  EAR. 

These  diseases  are  fortunately  less  frequent  than  those  of  the 
middle  ear.  They  are,  however,  relatively  more  frequent  in 
children  than  in  adults,  probably  for  the  reason  that  the  channels 
of  communication  between  the  internal  ear  or  labyrinth  are  more 
free  and  more  numerous  in  the  young.  The  causes  of  nerve 
deafness  are  the  infectious  fevers  and  the  exanthemata,  syphilis, 
leukocythemia,  diabetes,  Bright's  disease,  mumps,  meningitis, 
brain-tumors,  traumatism,  intense  sounds,  as  explosions  and  the 
like  ;  extreme  mental  strains,  such  as  fright,  and  angioneurotic 
congestion. 

The  symptoms  may  be  classed  as  (i)  irritative  and  (2)  par- 
alytic, and  include  subjective  noises,  hyperacuteness  of  hearing, 
dizziness,  vomiting,  loss  of  coordination,  and  loss  of  hearing. 
At  times  they  develop  slowly,  at  others  the  onset  is  sudden. 

The  prognosis  is  unfavorable,  as  a  rule,  though  at  times,  as 
when  due  to  syphilis,  hysteria,  or  medicines,  there  may  be  im- 
provement. 

Treatment. — This  should  be  directed  to  the  general  condition. 
Such  remedies  as  quinin,  iodid  of  potash,  mercurials,  pilocarpin, 
and  the  bromids  are  most  commonly  indicated.  Quinin  will  in- 
crease the  blood  supply  ;  bromids  decrease  it.  Iodid  of  potash 
tends  to  reduce  round-cell  infiltration  or  absorb  particles  of  in- 
flammatory tissue.  Pilocarpin  in  2  or  4  per  cent,  watery  solu- 
tion is  also  supposed  to  further  the  absorption  of  round  cells  or 
of  inflammatory  particles. 

Panotitis  is  a  form  of  ear  disease  occurring  chiefly  in  chil- 
dren,— often  in  the  course  of  diphtheria  or  scarlet  fever, — in 
which  there  is  a  suppurative  process  in  both  the  middle  ear  and 
labyrinth,  accompanied  with  high  fever  and  a  discharge  from 
both  ears,  and  terminating  in  deafness. 

Prognosis  in  this  disease  is  most  unfavorable,  total  deafness 
usually  resulting.  The  internal  administration  of  iodid  of  potash 
or  of  pilocarpin  may  be  of  some  benefit. 


CHAPTER   XVIII. 

GENERAL  CONSIDERATIONS  ON    PHYSICAL 
DEVELOPMENT 

WITH  SPECIAL  REFERENCE  TO  CHILDREN  OF  FEEBLE 
POWERS  AND  LOWERED  RESISTANCE. 


The  upbuilding  and  repair  of  all  children,  especially  those  who 
are  weakly  or  convalescent,  should  be  considered  on  broad  prin- 
ciples, the  basis  of  which  is  elaborate  thoroughness  and  abun- 
dance of  time.  This  involves  special  attention  to  dietetics,  in- 
cluding a  critical  estimation  of  varying  states  and  capacities  of 
digestion,  all  the  ordinary  hygienic  measures,  and  the  hopeful  use 
of  some  drugs.  There  must  be  insisted  on  for  such/both  during 
average  health  and  during  illness  and  convalescence,  more  rest 
for  the  mind  and  body  than  is  necessary  for  the  average  child. 
All  outings  and  exercises,  both  active  and  passive,  should  be 
supplemented  by  rest,  lying  down  for  as  long  a  time,  it  may  be 
minute  for  minute,  as  the  active  periods.  This  rest  is  necessary 
to  enable  lowered  organic  processes  to  regain  their  customary 
tone,  and  especially  to  secure  definite  gains.  It  will  often  be 
necessary  to  precede  food  by  a  period  of  rest,  to  enable  the 
digestive  activities  to  have  full  play  ;  otherwise  the  highly  sen- 
sitive nervous  distribution  to  the  digestive  apparatus  will  fail  of 
its  full  energizing.  Mental  or  emotional  agitation  impairs  the 
even  flow  of  the  circulation,  so  necessary  for  the  best  work  of 
weakened  organs,  particularly  the  brain,  whence  governing  im- 
pulses perpetually  flow,  dominating  the  body  and  spirit.  There- 
fore, too,  the  emotions  must  in  the  weakly  be  not  only  kept  well 
under  control,  but  subjected  to  the  least  possible  disturbance  or 
exaltation.  The  temperaments  (or  mental  attitudes  from  which 
they  view  life)  of  all  children  require  steady  and  patient  training. 
Even  in  the  home  a  clear  recognition  of  these  is  needed.  In  the 
case  of  strong  children,  equipped  with  clear,  dominant,  healthy 
minds,  it  is  undoubtedly  true  that  fair  results  come  somehow 
from  very  diverse  and  ill-directed  influences  ;  but  for  the  weaker 

792 


CASE  OF  FEEBLE  CHILDREN.  793 

ones,  impressionable  or  apathetic,  thorough,  conscientious  study 
and  specially  directed  measures  are  required. 

For  such  little  folk  it  is  not  enough  to  prescribe  suitable  medi- 
cines and  enumerate  casually  a  list  of  easily  digested  foods  which 
the  mother  shall  provide,  nor  to  direct  proper  bathings,  outings, 
and  other  general  measures.  A  thorough  systematization  of  the 
entire  daily  life  of  the  child  is  infinitely  more  efficacious  than  the 
most  accurately  selected  medicines  or  the  use  of  that  innumer- 
able host  of  children's  foods  with  which,  in  the  form  of  specious 
descriptive  circulars,  the  enterprising  chemists  flood  our  morning 
mails.  The  best  tonic  for  the  stomach  is  food  carefully  pre- 
pared, such  as  a  fairly  intelligent  mother  in  even  the  humblest 
walks  of  life,  if  rightly  directed,  can  readily  afford,  but  always 
provided  that  the  careful  preparation,  the  times  and  circumstances 
of  administration,  be  wisely  chosen  and  rigidly  adhered  to. 

Predigestion  of  food-stuffs  offers  undeniable  safeguards  to  the 
weakened,  toneless  digestive  tract,  but  robs  the  pabulum  too 
often  of  that  savoriness  which  is  essential  to  acceptability,  and 
hence  imperils  appetite. 

While  exercising  care  as  to  the  quality  and  preparation  of 
foods  for  weakly  or  convalescent  children,  it  is  imperative  to 
bear  in  mind  the  need  for  suitable  variety.  This  fact  we  have 
time  and  again  verified.  A  child  will  often  be  presented  who  is 
fed  with  the  utmost  care  and  regularity,  oftentimes  under  the 
best  of  medical  advice,  and  yet  its  progress  comes  to  a  standstill 
or  it  is  seen  obviously  to  retrograde.  Upon  inquiry  there  will 
be  revealed  much  sameness  in  the  diet-list,  otherwise  properly 
adjusted  to  the  condition  for  which  it  was  originally  outlined. 
The  little  victim's  soul  comes  to  loathe  and  abhor  the  sight  of 
flabby  paps,  occurring  in  dismal  routine,  or  the  same  old  weary- 
ing round  of  bread,  meat,  and  a  dab  of  vegetables.  If  to  these 
is  now  added  a  more  varied  dietary,  revising  the  menu  day  by  day, 
even  lapsing  into  a  taste,  now  and  again,  of  articles  ordinarily 
forbidden  yet  savory  and  tempting,  great  progress  will  soon  be 
obvious. 

The  growing  practice  of  sterilizing  milk  for  infants  and  chil- 
dren, invaluable  as  this  protection  is  for  temporary  use  during  hot 
weather  in  cities,  often  leaves  anemia  and  tonelessness,  even 
scurvy,  in  its  train  if  its  use  is  persisted  in.  There  is  a  value  in 
the  vital  properties  of  fresh  milk  not  to  be  produced  or  retained 
by  any  artificial  process. 

The  utmost  care  needs  to  be  observed,  however,  first,  in  the 
quality  of  the  milk,  which  includes  an  estimation  of  the  health 
of  the  cow ;  secondly,  strict  regulation  as  to  the  treatment  of 


794       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

the  milk  while  being  collected  and  immediately  thereafter,  and, 
finally,  the  greatest  conscientiousness  in  securing  cleanliness  of 
the  containing  vessels.  These  conditions,  though  difficult,  are 
becoming  more  and  more  possible  as  knowledge  grows,  and  if 
fulfilled,  will  bring  a  perfect  article  to  the  consumer. 

The  points  which  certainly  do  not  obtain  adequate  attention 
are  the  thorough  systematization  of  the  when,  where,  and  how 
much  of  these  foods  shall  be  taken  ;  what  varieties  shall  be  in- 
sisted upon  ;  the  times,  kind,  and  suitability  of  the  bath  ;  the 
amount  and  character  of  exercise,  and,  above  all,  definite  periods 
of  rest  before  and  after  feeding,  so  that  the  organs  shall  be  able 
to  act  deliberately.  First,  then,  when  confronted  with  an  ailing 
child,  one  who  is  not  ill,  but  far  from  well,  when  appetite  is  vari- 
able but  small,  when  sleep  is  restless,  the  digestive  organs  mani- 
festly disturbed  and  temper  fretful,  one  that  fails  to  hold  its  own 
in  play  among  its  fellows,  and,  what  may  not  be  ignored,  whose 
weekly  school  report  shows  decided  backsliding — first,  look  the 
little  fellow  over  thoroughly  and  in  all  respects. 

There  may  not  be  one  organ  more  amiss  than  another,  though 
the  most  obvious  faults  will  usually  be  seen  in  that  avenue  to  all 
vital  power,  the  prima  via.  There  may  be  yet  no  falling  off  in 
weight,  a  far  more  instructive  index  in  a  child  than  in  an  adult, 
nor  an  obvious  anemia.  There  may  be  a  quicker  pulse  than 
ordinarily,  a  change  in  the  heart-sounds  which  the  initiated  will 
recognize  but  can  not  so  clearly  describe  ;  there  probably  will 
be  found,  if  so  much  trouble  is  taken,  a  rise  in  temperature, 
slight  but  unmistakable  at  times,  at  others  subnormality  well 
marked,  and  there  is  great  probability  that  neither  the  attention 
nor  other  exertion  is  readily  sustained.  The  child,  in  marked 
contrast  to  its  healthy  comrades  and  itself  at  other  times,  is 
willing  to  sit  aimlessly,  if  not  a  martyr  to  energetic  task-masters 
or  to  an  overstrenuous  conscience  which  drives  its  willing  victim 
to  the  verge  of  perpetual  exhaustion,  and  often  over  it  into  the 
pit  of  complete  collapse. 

Such  cases  as  here  pictured  are  common  enough,  if  only  the 
eyes  are  open  to  see  them.  They  escape  attention  only  too 
readily  until  some  malady  seizes  them  in  all  their  pitiable  weak- 
ness, and  life  is  speedily  quenched.  It  is  a  worthy  quest,  then, 
to  seek  out  and  rescue  these  from,  it  may  be,  no  picturesque  fate, 
but  an  everpresent  menace  ;  to  rehabilitate  these  unresilient  little 
bodies  and  even  make  them  better  than  before  ;  to  put  them  in 
the  way  of  a  sound  bodily  equipment  for  their  life-work  anon. 

Here  is  a  sketch  of  modified  rest  treatment  which  produces 
excellent  results  when  all  other  efforts  have  failed  to  start  a  child 


DEVELOPMENT    OF    SENSE    ORGANS.  795 

along  the  line  of  progress.  Put  the  little  one  in  bed  from  a  few  days 
to  a  week  or  more,  and  write  down  distinctly  for  the  mother  a  strict 
schedule,  giving  the  exact  hours  for  feeding.  These  may  be  the 
ordinary  three  meals,  with  some  little  fluid  food  taken  in  between 
times,  or,  better,  direct  four  meals  to  be  given  in  the  day,  at,  say, 
seven,  twelve,  four,  and  eight  o'clock,  the  largest  meal  at  noon. 
Omit  the  tonics  hitherto  given  and  add  digestive  ferments  or 
malt,  or  both.  Let  the  day  begin  with  a  sponge-bath  in  a  warm 
room  ;  then  a  light  breakfast,  daintily  served.  In  the  early 
afternoon  let  some  one  rub  into  the  trunk  and  limbs  an  oil  ;  olive 
oil  will  do  and  much  of  it  is  thus  absorbed,  especially  if  one-third 
part  soap  liniment  is  added,  which  probably  aids  the  osmotic 
action.  Lanolin,  diluted,  is  best  of  all ;  changes  are  desirable 
in  all  skin  applications.  This  serves  as  a  form  of  passive  exer- 
cise and  also  as  a  nutriment,  or  at  least  as  a  tonic  to  the  skin, 
circulation,  and  cutaneous  nerves.  The  surface  should  be  thor- 
oughly wiped  off  afterward,  that  no  foulness  remain.  We  have 
seen  children  immensely  benefited,  even  among  the  poorest  dis- 
pensary cases,  from  this  one  measure  alone.  Above  all,  in  the 
early  course  of  these  measures,  if  the  child  manifests  a  desire 
for  toys,  they  may  be  allowed  sparingly,  but  aggressive  enter- 
tainment by  overofficious  persons  is  a  harm  and  an  offense  and 
should  be  strictly  forbidden.  After  a  few  days  or  a  week  the 
range  of  one  sunny  room  may  be  permitted,  but  still  the  child 
should  be  let  alone,  and  in  most  cases  it  will  be  happy  and 
amuse  itself. 

Frail  children  require  systematic  development  of  their  various 
organs,  as  well  as  of  their  muscles.  To  be  sure,  it  seems  scarcely 
practicable  to  increase  the  power  of  some  organs,  as  the  stomach 
or  kidney  ;  nevertheless  it  is  possible  to  do  so.  It  is  abundantly 
obvious  that  the  eye  and  the  lungs  and  the  skin  can  be  devel- 
oped, and  it  is  equally  important  that  all  these  organs  should 
receive  attention  in  the  aggregate  and  separately,  especially 
where  there  is  a  manifest  underdevelopment  of  the  one  or  the 
other,  which  then  should  receive  specific  attention. 

To  take,  first,  the  eye.  An  infant  can  sustain  very  consider- 
able damage  to  its  eye  by  objectionable  exposure  to  light,  which 
may  be  too  strong,  too  sudden,  or  too  constant.  It  may  readily 
have  its  eye  muscles  disturbed  by  a  habitual  attitude,  as  when, 
by  reason  of  a  weak  back  or  other  disability,  it  is  confined  to  a 
single  place,  as  a  chair,  in  a  customary  situation  in  the  same  room, 
straining  vision  in  one  way,  and  many  other  objectionable  prac- 
tices which  common  sense  and  observation  will  make  evident. 
By  the  same  token  this  eye  or  pair  of  eyes  may  become  devel- 


796       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

oped,  not  only  in  their  organic  capacities,  in  the  judging  of  dis- 
tances, inviting  refractive  adjustments,  etc.,  but,  as  intelligence 
increases,  great  good  can  be  accomplished  by  a  thoughtful  use  of 
interesting  objects  which  may  excite  the  child's  wholesome  in- 
terest and  educate  its  perception. 

There  are  experiments  now  afoot,  at  least  promising  well,  by 
which  children  can  be  taught  so  to  perceive  differences  of  color,  in 
form,  and  the  arrangement  of  objects,  as  will  greatly  facilitate 
their  comprehension  of  natural  phenomena.  It  is  quite  possible 
that  along  this  line  may  be  found  means  to  prevent  defects  of 
sight,  such  as  color-blindness,  as  well  as  to  check  the  progress 
of  myopia  and  other  refractive  errors.  There  is  great  unwisdom 
in  submitting  babies  to  rapid  journeys,  and  looking  out  of  windows 
at  swiftly  passing  objects  while  flying  along.  We  have  seen 
migraine  apparently  develop  through  the  custom  of  giving  small 
children  long  exercise  in  a  carriage  with  a  pair  of  fast  horses 
every  day.  We  have  certainly  seen  instances  of  profound  dis- 
turbance caused  by  this  means,  and  it  is  reasonable  to  infer  that 
a  continuance  of  such  objectionable  measures  may  produce  last- 
ing damage  upon  so  delicate  an  organ  as  the  eye,  and  the  whole 
sensitive  organism  is  thus  imperiled. 

The  custom  of  encouraging  a  child  to  sleep  while  being  driven 
about  is  unwise.  The  motion  is  both  tiresomely  regular  and  sub- 
ject to  sudden  irregularities.  The  persistence  of  one  kind  of 
motion  up  and  down  is  bad,  not  only  producing  relatively  un- 
sound sleep,  but  keeping  up  a  molecular  agitation  throughout 
which  has  little  to  recommend  it.  If  the  infant  is  awake  and 
sufficiently  old  and  alert  to  sit  up  and  look  about,  or  to  be  for- 
cibly held  by  the  nurse  in  an  upright  position,  a  strain  is  put 
upon  the  spinal  column.  Thus  continuous  mild  concussions  are 
administered  to  the  spinal  cord  and  brain  ;  thus  the  eye  is  put 
upon  the  strain,  reacting  directly  upon  the  brain  ;  an  element  of 
excitement  is  introduced,  and  physiologic  irritability  is  a  probable 
result. 

The  heart  is  capable  of  much  improvement,  and  demands  the 
closest  attention  to  varying  states.  If  a  baby  starts  out  with 
an  organically  sound  heart  and  succeeds  in  getting  its  whole 
mechanism  so  developed  (by  living  under  wholesome  conditions, 
which  involves  some  systematic  training,  whether  this  come  by  de- 
sign or  accident)  as  to  steadily  increase  its  vigor  and  competence, 
then  the  heart  will  be  the  very  foundation  of  future  power  and 
the  ground  of  reliance  when  illness  or  strains  come.  It  will 
serve  valiantly  to  the  end  of  great  age,  spent  under  manifold 
exigencies,  both  physical  and  mental.  In  the  repair  of  damaged 


DEVELOPMENT    OF    THE    SKIN. 

hearts  mental  rest  is  of  more  importance  than  physical  in- 
activity. Moreover,  there  are  more  perilous  cardiac  states 
than  valvular  diseases,  though  they  may  not  be  so  demon- 
strable. Judicious  attention  to  a  weak  or  damaged  heart  can 
accomplish  much  and  is  best  afforded  in  the  line  of  regulated 
activities. 

The  development  of  the  skin  is  of  paramount  importance  in 
the  young,  as  upon  its  capacity  to  endure  changes  in  tempera- 
ture and  other  states  will  depend  much  of  the  future  healthful- 
ness  of  the  individual.  Some  children  have  the  layers  of  the 
skin  unformed  from  the  first,  and  it  never  acquires  normal  activ- 
ity. There  is  quite  a  large  variety  of  skins  obviously  different 
to  observant  persons — the  firm,  glossy,  velvety  skin  of  health, 
the  pallid,  flabby,  or  leaky  skin,  readily  becoming  overmoist, 
loosely  attached  and  wrinkling  readily,  or  the  yellow,  harsh  skin, 
either  flabby  and  toneless,  or  stiff  and  inelastic,  adhering  to  the 
bone,  or  seeming  to  do  so.  Some  skins  are  insensitive  and  react 
to  almost  no  stimulant  ;  others  chafe  and  get  out  of  order  if 
only  thin  clothing  press  upon  them,  hypersensitive  to  the  simplest 
hurtful  agencies. 

The  skin  of  a  red-haired  child  is  always  tender  and  usually 
beautiful.  Children  predisposed  to  tuberculosis  or  scrofulosis 
have  poor  skins,  which  can  be  and  should  be  immediately  im- 
proved. Various  neuroses  show  in  the  skin.  In  short,  the 
surface  of  the  body  is  of  vast  activity,  and  the  cultivation  of  this 
large  part  of  the  organism  is  of  critical  importance. 

Now,  as  to  the  means  of  improvement  in  our  control.  We 
believe  if  babies  were  anointed  from  the  first  with  oil,  and  cleansed 
by  rubbing  them  off,  not  using  water,  or  but  sparingly,  for  weeks 
or  months,  their  skins  would  become  more  vigorous  than  when 
soap  and  water  are  freely  used.  This  we  have  proved  by  a 
series  of  cases  observed  (and  published),  three  of  whom  were 
our  own  offspring.  Exposure  of  the  skins  of  infants  to  the  air 
of  an  equably  heated  room  is  wholesome,  and  they  are  better 
for  as  much  exposure  as  possible,  always  short  of  chills.  In 
America  we  are  subject  to  such  sudden  and  extreme  changes 
that  we  dare  not  allow  this  so  freely  as  is  safe  in  many  other 
countries.  The  exposure  of  knees  and  shoulders  in  children  not 
the  most  robust  is  dangerous,  unless  carefully  watched  and 
promptly  covered  at  the  approach  of  chilling  conditions.  In- 
doors it  is  of  use,  outdoors  not  to  be  recommended-  at  all.  To 
go  barefoot  is  wholesome  for  many.  Almost  never  do  children 
hurt  their  feet,  and  thus  only  are  the  feet  symmetrically  de- 
veloped. They  do  not  increase  in  size  seriously.-  We  know  of 


798       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

numbers  of  Southern  girls  with  feet  entirely  beautiful  who  ran 
barefoot  in  warm  weather  until  they  were  almost  grown. 

Cautious  and  repeated  exposures  induce  an  increasing  tolerance 
of  the  skin  which  will  greatly  strengthen  the  whole  organism. 
The  clothing  at  no  time  should  be  any  more  than  is  necessary  to 
protect.  Overswathing  lessens  energy ;  it  throws  the  volatile 
elements  of  excretion  back  into  the  blood  and  thus  directly  poi- 
sons. The  skin  should  be  able  to  throw  away  entirely  and 
promptly  its  effluvia,  which  should  be  offered  free  escape,  or  its 
retention  may  damage  the  lungs  or  kidneys.  When  we  bear  in 
mind  the  capacity  of  the  surface  blood-vessels,  and  how  greatly 
vascular  dilatation  or  contraction  alters  the  state  of  the  varying 
blood  supply  to  internal  organs,  also  how  large  is  the  amount  of 
matter  excreted  by  the  skin,  and  many  other  points  involved  in 
its  functional  activities,  we  at  once  recognize  the  importance  of 
preserving  its  integrity  at  all  times.  If  these  activities  are 
anatomically  undeveloped  or  functionally  impaired,  they  demand 
our  closest  attention.  Natural  means  are  best,  judiciously  con- 
trolled. Exposure  is  important,  always  with  caution.  Bathing 
should  be  frequent, — daily,  indeed,  or  in  hot  weather  oftener, — 
in  as  cool  water  as  can  be  enjoyed  or  well  endured,,  but  gradu- 
ally lowered  if  unaccustomed.  Bathing  should  be  followed  by 
thorough  drying  and  rubbing  and  prompt  covering  ;  weakly  folk 
should  lie  down  for  a  time  after.  If  chilled,  let  them  get  into  bed 
for  a  time  until  complete  reaction  comes  or  fatigue  goes.  When 
bathing  can  not  be  so  well  endured,  at  least  as  often  as  may  be 
indicated,  then  a  dry  rub  will  suffice,  especially  after  exertion 
and  exceptional  opening  of  the  pores.  If  all  this  tires  the  child, 
it  should  lie  down,  and  the  work  be  done  for  him  by  another 
person.  Soaps  are  to  be  used  sparingly  and  only  for  cleansing. 
Salt  is  almost  as  cleansing  and  more  stimulating.  If  the  skin  is 
tender,  bran  decoctions  added  to  the  bath  will  soothe.  Ammonia 
or  sulphur  added  to  the  water  has  value,  rendering  it  soft  and 
exerting  special  effects.  To  begin  cold  bathing,  let  one  unac- 
customed stand  in  three  inches  of  warm  water  and  be  sponged  off 
in  cool  and  cooler  water.  The  custom  of  the  Greeks  to  exercise 
naked  anointed  with  oils  has  much  to  commend  it.  The  rolling 
in  the  sand  of  the  arena  in  wrestling  was  accredited  with  benefit, 
and  no  doubt  rightly.  Wading  at  the  seashore  and  digging  in 
the  sand  is  analogous,  and  much  to  be  commended  if  not  too 
prolonged.  Swimming  comes  next  to  bathing,  and  is  among  the 
finest  agencies  for  invigoration  of  skin  and  muscles.  Remaining 
in  the  water  longer  than  half  an  hour  is  of  doubtful  value,  and 
over  an  hour  is  a  strain,  and  for  several  hours  is  hurtful  to  any 


nc 

DEVELOPMENT  OF  THE  LUNGS.  799 

but  the  strongest,  and  does  them  no  good.  Water  colder  than 
the  air  of  the  bath-room  is  often  hurtful  for  the  strongest  and  of 
little  or  no  value  to  any.  Shower-baths  and  needle-baths  are 
terrifying  to  most  children,  and  possess  no  advantage  over  spong- 
ing or  plunging.  It  is  best  for  little  folk  to  encourage  cool 
bathing  by  gentle  gradations,  and  to  make  of  it  a  reward  or 
frolic.  The  air  of  the  bath-room  should  be  warm. 

The  exercise  of  the  lungs  next  to  the  skin  requires  much 
attention.  First,  it  is  necessary  to  make  sure  that  the  avenues 
to  the  lungs — the  nose  and  throat — shall  be  clean  and  healthy. 
Upon  proper  lung  action  depends  the  aeration  and  purity  of  the 
blood,  and  through  these  the  complete  activity  of  the  remotest 
organ.  Upon  the  integrity  of  the  epithelium  of  the  respiratory 
passages  depends  in  great  measure  the  defense  of  the  organism 
against  the  onslaughts  of  many  microbic  poisons. 

The  nose  and  nasopharynx  must  be  kept  free  from  irritations 
and  pathologic  changes,  which  might  limit  function  or  obstruct 
the  in-and-out  go  of  the  air.  Upon  the  competence  of  the  lung 
expansion  will  depend  the  completeness  of  the  oxygenation  and 
the  competence  of  especially  those  portions  of  the  lung  which 
are  less  liable  to  a  full  distention,  as  the  apices,  so  rarely 
developed  and  so  vulnerable,  and  also  the  lower  borders.  The 
development  of  the  lungs,  of  course,  is  more  commonly  obtained 
through  normal  activities,  but  if,  for  any  reason,  these  are 
impaired — as,  for  instance,  lameness,  an  enfeebled  or  damaged 
heart,  or  a  weak,  nervous  organization — and  the  child  is  not 
able,  or  it  may  be  unwilling,  or,  at  least,  indisposed,  to  take 
wholesome  action  and  exercises,  then  it  is  essential  not  to  lose 
sight  of  the  necessity  of  getting  these  lungs  sufficiently  dilated 
by  regulated  exercises  for  their  proper  growth  and  the  contin- 
uance of  their  integrity.  For  feeble  children  it  is  convenient  to 
induce  them  to  play  at  certain  games  which  may  involve  deep 
respirations  and  forcible  blowings.  Indeed,  one  of  the  first 
accomplishments  to  teach  a  child  is  to  blow  its  nose  properly. 
Pretty  much  every  child  in  America  inherits  or  may  develop  a 
condition  of  nasopharyngeal  catarrh.  Among  the  Greeks  it  was 
considered  a  degradation  to  be  obliged  to  blow  the  nose,  and  a 
most  impolite  thing  to  do  ;  but  the,  reason  for  that  was  their 
perfect  health,  and  a  large  part  of  this  was  the  magnificent 
attention  their  skins  received  throughout  their  earlier  and  later 
years. 

All  children  will  almost  invariably  acquire  occasional  catarrhs, 
and  they  should  be  early  taught  to  free  the  nose  of  morbid  or 
excessive  secretions.  The  way  to  do  this  is  to  teach  them  to 


8OO       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

blow  a  long,  steady  blast,  holding  the  handkerchief  against  one 
nostril  the  while,  and  then,  holding  the  opposite  nostril,  to  take 
a  long  inspiration,  and  then  to  blow  steadily  out  of  the  other 
one.  And  then,  if  not  free,  to  repeat  the  process  on  alternate 
sides,  at  least  twice,  but  never  explosively.  Then  the  air  comes 
and  goes  freely,  as  it  should,  to  the  lungs,  suitably  warmed  and 
screened. 

Hearing  also  needs  attention  in  the  same  way.  As  is  well 
known,  those  children  who  habitually  hear  good  music  have 
this  sense  perception  better  developed.  The  sense  of  smell, 
while  deserving  of  attention,  is  rather  more  likely  to  be  over- 
developed to  the  point  of  squeamishness  than  to  suffer  any  lack 
in  this  direction,  seeing  that  in  the  evolution  of  the  race  the  nose 
is  of  clearly  less  use  than  in  the  savage  state. 

In  the  matter  of  taste  this  merely  need  be  alluded  to.  It 
warrants  attention,  but  rather  on  esthetic  than  practical  grounds. 

Forms  of  Exercises  and  Outings. — Every  element  of  ex- 
citement, not  forgetting  oversolicitous  attention  and  forced 
amusements,  should  be  deprecated  and  avoided  until  children 
acquire  genuine  vigor.  Excitable  children  need  to  be  watched 
with  the  utmost  care,  and  the  element  of  strain,  wherever  de- 
tected, should  be  sedulously  removed.  For  very  young  babies 
merely  keeping  them  in  the  open  air  is  of  great  value.  They 
should  be  sufficiently  clothed,  but  not  suffocated.  The  rule 
should  be  just  enough  and  of  the  right  kind,  but  not  one  bit  too 
much  ;  reserve  overclothing  to  be  near  at  hand  always.  In  bitter- 
cold  weather  veils  are  of  great  importance,  always  of  sufficiently 
open  mesh  for  the  air  to  get  readily  through,  but  to  protect  from 
the  rougher  winds.  This  veil,  upon  occasion,  may  be  doubled, 
and  had  better  be  of  dark  color  and  natural  tint.  For  the  poor, 
a  piece  of  cheese-cloth  will  suffice.  Veils  should  be  washed  or 
at  least  cleansed  frequently,  as  a  great  deal  of  objectionable 
matter,  both  from  the  expired  air  and  from  floating  dust,  may 
accumulate  upon  them  and  be  inbreathed  again. 

There  is  a  prejudice  against  a  baby  or  a  child  sleeping  in  the 
open  air.  If,  however,  it  is  sufficiently  wrapped  up,  no  harm  can 
result.  During  sleep  relaxation  occurs,  especially  with  children 
of  tender,  leaky  skins,  and  surface  chills  may  arise,  but  these 
need  not  occur  if  precautions  are  used.  A  valuable  form  of 
exercise  and  an  adequate  outing  are  had  by  allowing  a  child 
from  three  to  five  years  old  to  play  about  in  a  room  with  the 
windows  wide  open,  and  with  its  usual  extra  clothing  on,  such 
as  is  worn  when  taking  its  ordinary  walks  abroad.  This  form 
of  outing  can  be  enjoyed  anywhere,  at  any  time,  for  any  given 


FORMS    OF    EXERCISES    AND    OUTINGS.  8OI 

length  of  time,  and  the  perfection  with  which  it  may  be  con- 
trolled is  of  the  greatest  advantage.  Furthermore,  by  these  means 
the  caretaker  watching  may  remain  with  the  child  and  utilize  the 
time  by  pursuing  some  employment  in  useful  fashion  the  while. 
An  apathetic  little  one,  who  without  constant  urging  will  quietly 
sit  down  and  do  nothing,  may  be  kept  busy  or  amused  ;  and  per 
contra,  a  rustling,  bustling  little  one,  who  would  readily  overdo, 
may  be  thus  held  in  check. 

Children  of  weak  lungs  or  insufficient  lung  expansion  or  with 
a  predisposition  to  phthisis  may  be  taught  regulated  breathings 
to  great  advantage.  A  useful  measure  also  is  to  institute  for 
these  some  games,  such  as  blowing  through  a  tube,  as  shooting 
of  peas  through  a  tube  at  a  mark — a  very  practical  means  of 
increasing  thoracic  size  and  lung  power.  An  excellent  indoor 
game  is  the  old-fashioned  bean-bag,  at  which  the  nurse  can  be  a 
companion,  and  thus  a  perfect  regulation  can  be  established  of 
the  amount  of  energies  employed.  This  bag  of  beans  may  be 
tossed  back  and  forth  so  many  times,  and  at  different  distances, 
increasing  them  from  day  to  day  and  week  to  week.  Both 
hands  may  at  first  be  used,  and,  later  on,  as  strength  grows, 
the  one  hand  or  the  other,  not  neglecting  either.  Both  the 
right  hand  and  the  left  may  thus  have  their  adequate  em- 
ployment, and  even  for  stronger  children  this  is  of  excellent 
utility. 

The  next  step  in  this  direction  is  the  use  of  the  medicine  ball, 
which  in  our  larger  gymnasia  has  become  quite  the  fashion. 
This  so-called  "  medicine  ball"  is  merely  a  sphere,  made  up  of 
soft  material,  weighing  from  one  to  six  or  seven  pounds,  and 
covered  with  soft  leather,  the  rough  surface  out.  For  little  chil- 
dren it  may  be  about  the  size  of  an  orange,  or  preferably  a  little 
larger,  as  being  convenient  to  hold  in  two  hands.  This,  passed 
or  tossed  from  one  to  another,  requires  more  skill  than  the  bean- 
bag,  and  may  be  used  in  the  same  way  that  a  foot-ball  is  thrown 
and  caught,  either  with  two  hands  or  one  hand,  and  soon  a  very 
large  measure  of  skill  is  acquired  and  interest  incited.  When  the 
regulation  or  prescribed  amount  of  passing  has  been  done,  then 
it  can  be  stopped  for  one  or  all  the  players.  A  watchful  care- 
taker may  learn  this  amount  for  himself  or  herself,  or  act  under 
specific  instruction  as  what  to  do  and  what  not  to  do. 

The  most  important  element  in  all  games  is  the  incentive  of 
competition,  even  if  that  competition  be  with  one's  own  self.  In 
all  those  exercises  which  are  devised  for  the  purpose  of  keep- 
ing up  a  consistent  interest  a  much  larger  amount  of  activity  may 
be  used,  and  with  less  reactionary  fatigue  than  with  any  form  of 


8O2       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

exercise  which  fails  of  this  quality,  no  matter  how  eagerly  one 
may  pursue  it  as  a  measure.  The  converse  point  is,  however, 
that  vivid  interest  may  cause  a  weakly  person  to  do  too  much, 
even  when  he  is  endeavoring  to  execute  some  act  with  skill  in 
which  he  himself  is  the  only  competitor.  When,  however,  the 
competition  is  with  others,  the  element  of  excitement  is  added, 
which  may  become  harmful  to  those  insufficiently  strong.  Of 
games,  many  of  the  larger  competitive  kinds  are  manifestly  unfit 
for  children  not  overstrong.  Match  games  of  foot-ball,  or  even 
base-ball,  are  out  of  the  question.  Milder  competitions,  as  in 
shinny  or  rowing,  are  of  doubtful  value  ;  but  golf  is  a  perfect 
game,  and  can  be  regulated  for  the  feeble  and  the  strong,  the 
young  and  the  old,  of  either  sex. 

The  evidences  of  overexercise  in  children  or  in  weakly  persons 
must  be  carefully  noted.  Mere  breathlessness  is  no  objection, 
and  is  easily  recovered  from  if  the  organs  are  sound.  Also, 
a  pretty  free  sweating  is  harmless  enough  unless  this  goes  to  the 
point  of  saturating  the  underclothing,  hence  exposing  one  to 
secondary  chill.  If,  however,  with  very  small  exertion  sweating 
comes  readily,  and,  instead  of  being  accompanied  by  a  normal 
reddening  of  the  surface  and  the  face,  the  person  becomes  pallid 
or  bluish  and  loses  the  normal  luster  or  brightness  of  the  eye, 
then  caution  must  be  observed.  If  after  small  exertion  there  is 
seen  a  sort  of  trembling  of  the  limbs,  the  face,  and  the  lips,  this 
means  that  enough  has  then  been  done,  and  possibly  too  much. 
If  seen  habitually  in  the  same  individual,  the  amount  of  exer- 
cise must  be  limited  until  by  slow  degrees  and  through  other 
means  adequate  strength  is  acquired.  Soreness  in  the  muscles 
afterward  is  of  no  gravity,  though  often  a  source  of  anxiety. 

It  is  a  good  point  to  note  the  face,  whether  it  be  ruddy,  pallid, 
or  bluish,  as  an  indication  of  benefit  or  harm  from  exercise  ;  not 
that  it  is  infallible,  because  some  powerful  athletes,  men  of  greatest 
endurance,  become  pale  while  in  action.  This  is,  however,  un- 
usual. The  pulse  is  a  useful  indicator,  too,  and  while,  of  course, 
even  the  most  vigorous  people  who  are  in  moderate  condition 
have  their  heart  action  immensely  accelerated  under  sustained 
exertion,  nevertheless  this  excessive  rapidity  and  loss  of  force 
usually  mark  the  limit  of  their  capacity,  and  the  effort  must  not 
be  kept  up  too  long,  as  under  excitement.  If  the  person  is  in 
good  condition,  he  is  likely  to  have  a  full,  strong  pulse,  only  a 
little  quickened  over  his  ordinary  rate. 

We  have  repeatedly  examined  the  pulse  and  heart  of  boys 
under  varying  strains,  such  as  a  prolonged  foot-ball  game  or  base- 
ball match,  in  which  there  was  pretty  constant  action,  and  have 


FORMS    OF    EXERCISES    AND    OUTINGS.  803 

noted  that  the  condition  of  the  pulse  in  those  otherwise  in  equal 
condition  varied  very  much  with  their  excitability.  And  inas- 
much as  this  excitability  of  the  person  reflected  upon  the  pulse 
means  rapid  using-up  of  pabulum  and  rapid  oxidization,  along 
with  wear  and  tear  of  the  nerve  and  other  cells,  therefore  it 
is  fair  to  assume  that  the  rapidity  of  the  pulse  is  a  good  indi- 
cation of  the  using-up  of  vigor.  If  the  strain  on  the  heart  is 
too  severe,  the  result  will  be  a  proportionate  exhaustion.  The 
tissues  of  young  folk  are  so  clean  and  elastic  that  an  excess  of 
intravascular  pressure  can  exert  less  harm  than  in  the  case  of 
adults.  The  heart  not  only  needs  to  be  of  proper  size,  shape,  and 
tissue  competence  to  fit  the  body,  but  the  tension  in  the  arteries 
and  the  quality  of  its  venous  competence  may  be  ample  or  lack- 
ing ;  when  this  is  below  par,  the  heart  acts  irregularly  and  la- 
boriously, and  is  easily  wearied  and  its  force  soon  spent.  This  is 
shown  in  dyspnea  and  palpitation,  "  air  hunger,"  "  besoin  de  re- 
spirer"  ;  if  long  continued,  the  result  is  cardiac  asthma.  This 
phenomenon  is  frequently  observed  in  the  healthy  under  cus- 
tomary exertion  ;  it  is  then  chiefly  due  to  the  normal  phenomena 
of  insufficient  elimination  of  the  products  of  tissue  waste,  and  is 
comfortably  met  by  a  few  minutes'  deep  breathing  or  ample  oxy- 
genation,  and  most  economically  lying  flat  on  the  back,  arms  and 
legs  outstretched,  the  head  retracted  and  the  mouth  open. 

For  children  younger  or  older  the  very  best  form  of  outing  is 
to  potter  about  a  large  garden,  doing  a  little  here  and  there  and 
then  resting  a  while.  The  acts  involved  in  gardening,  the  dig- 
ging and  pruning  and  various  forms  of  activity  essential  thereto, 
are  by  far  the  healthiest  forms  of  exertion  known  to  man. 
Indeed,  the  age  of  gardeners  is  unusually  prolonged,  provided 
they  live  wholesomely  conditioned  lives  otherwise.  Farm-work 
is  a  different  matter,  involving  greater  strains.  But  the  work  of 
the  garden,  under  intelligent  supervision  or  advice,  which  is 
followed,  is  suitable  for  young  or  old,  and  is  of  the  largest  pos- 
sible utility. 

For  girls  or  feebler  boys  the  cultivation  of  flowers  in  boxes, 
or  window-gardening,  is  a  healthful  occupation.  The  care  of 
small  animals  or  of  fish,  as  of  birds  or  small  four-legged  pets, 
the  making  and  caring  for  aquaria  and  such-like  things,  are  ex- 
cellent as  sustaining  interest  and  supplying  some  form  of  activity 
and  variety  without  strain.  The  study  of  botany  and  field 
botanizing  are  among  the  best. 

The  study  of  birds  in  their  natural  haunts — watching  their 
conduct,  listening  to  and  recording  their  songs,  keeping  the  eyes 
upon  their  movements,  especially  with  a  field-glass — is  of  infinite 


804       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

interest.  So,  also,  of  the  woodland  moving  things,  not  neglect- 
ing even  ants  and  spiders,  although  using  all  due  precautions  in 
approaching  the  latter. 

For  older  boys,  even  of  the  sickliest,  provided  they  have  the 
use  of  their  limbs  and  reasonable  integrity  of  their  organs,  there 
is  no  one  form  of  life  which  so  largely  conduces  to  the  building 
up  of  nervous  force  and  muscular  vigor  as  camping  out  in  the 
woods.  There  is  so  much  to  be  said  on  this  subject — right  sort 
of  camp  protection  and  varying  conditions — that  it  is  only  pos- 
sible to  allude  to  it  with  the  statement  that  our  experience  has 
been  fairly  large,  admitting  of  an  expression  of  opinion,  though 
few  rules  can  be  formulated  short  of  a  long  essay. 

The  life  of  a  boy  under,  of  course,  proper  control  in  the 
woods,  far  away  from  civilization,  is  as  near  as  possible  to  per- 
fection, to  the  vitalizing  influences  of  aboriginal  nature.  He  is 
freest  there  from  all  those  minor  and  major  disturbing  influences, 
excitements,  artificial  restrictions,  or  spontaneity  which  permits  of 
healthy  growth,  mental  and  physical,  encourages  symmetry,  and 
fortifies  against  warpings. 

We  have  advised  this  life  for  a  boy  not  ill,  but  still  far  from 
strong,  about  whom  it  was  most  natural  to  be  gravely  apprehen- 
sive lest  the  experiment  should  fail  or  prove  disastrous  ;  never- 
theless, without  himself  being  at  first  particularly  pleased  with 
the  experience,  this  camp-life  succeeded  in  accomplishing  what 
no  other  combinations  had  been  able  to  do,  even  of  the  most 
carefully  selected  or  expensive  kinds.  The  irregularity  of  feed- 
ing, lack  of  sleeping  comforts,  the  loss  of  various  civilized 
necessities  notwithstanding  were  offset  with  best  effect  by  the 
simplicity  of  life  ;  the  element  of  independence  of  little  things 
ordinarily  provided  and  thought  to  be  needful  ;  the  absolute 
naturalness  of  motions  and  attitudes  and  things  done  ;  the 
early  hours  to  bed  and  even  earlier  to  rise  ;  the  constant  breath- 
ing of  perfect  air,  whether  by  night  or  day,  wet  or  dry,  it 
mattered  not,  and  many  other  points  too  numerous  to  mention, 
produced  a  result  most  satisfactory.  When  in  doubt,  it  is  always 
well  to  resort  hopefully  and  fearlessly  to  such  conditions. 

Morals  and  religion  in  these  surroundings  need  little  teaching, 
— a  hint  will  suffice,  and  this,  to  the  narrowed  mental  horizon  of 
a  young  person,  is  a  vastly  important  point, — and  nowhere 
better  than  in  the  woods  or  wilds.  Confusion  is  usually  pro- 
duced in  the  concepts  by  special  or  didactic  ethic  teaching,  and  it 
is  a  much  worse  thing. than  ignorance,  which  is  a  clear  field  for 
the  intuitional  understanding. 

Development  of  Muscles. — There  is  still  an  impression  pre- 


DEVELOPMENT    OF    THE    MUSCLES.  805 

vailing  among  even  the  best  teachers  of  physical  culture  that 
development  of  the  muscles  exerts  of  itself  a  particularly  valuable 
influence  upon  the  general  constitutional  vigor.  A  good  deal  of 
attention  is  directed  by  writers  on  this  subject,  and  to  various 
means  of  cultivating  muscular  power.  This  is  true  only  to  a 
very  moderate  extent.  To  be  sure,  the  exercising  of  the  muscles 
can  scarcely  be  carried  on  independently  of  certain  collateral  co- 
ordinative  acts  involving  the  healthy  energizing  of  the  vital 
organs.  By  quickening  their  activity  by  that  of  the  circulation  and 
stimulating  the  ebb  and  flow  of  the  blood  throughout  the  motor 
mechanism  this  does  improve  nutrition,  and,  to  a  certain  degree, 
enhances  generally  the  vigor  and  power  of  the  whole  economy. 
Exercising  the  muscles  in  vigorous  persons  with  sound  and  com- 
petent organs  adds  to  the  usefulness  of  the  trunk  and  limbs, 
enlarges  their  capacities,  and  is  of  permanent  value.  In  the  class 
of  cases  under  discussion  this  is  also  true,  but  with  many  impor- 
tant modifications.  The  heart  may  be  thus  hypertrophied  or 
weak  spots  unduly  strained.  The  most  important  condition  of 
the  muscles,  voluntary  and  other,  which  can  be  attained,  is  a 
well-balanced  elasticity. 

Let  us  review  for  a  moment  the  different  kinds  of  muscular 
actions,  their  mechanism  and  physiology.  There  are  the  vol- 
untary and  the  involuntary  muscles  ;  ordinarily  only  the  former 
are  considered  under  the  subject  of  exercise.  The  effect  upon 
the  involuntary  muscles  is  a  very  important  one,  however,  and 
precedes  and  should  proceed  pari  passu  with  the  stimulation  of 
the  voluntary  mechanism.  It  is  conceivable — and,  indeed,  we 
have  seen  instances  which  illustrated  this — where  individuals 
have  acquired  a  species  of  muscular  monstrosity  by  having  their 
voluntary  muscles  so  exercised  as  to  increase  their  size  and  power 
out  of  all  proportion  to  the  organic  capacity  of  the  individual. 
This  produces  an  overgrowth  of  a  kind  which  is  not  only  almost 
valueless,  but  a  distinct  menace  and  an  evil  example.  In  the  ex- 
ercise of  the  limbs  we  may  divide  the  kinds  of  energy  into  those 
of  swiftness  or  speed  and  of  power,  which  may  be  again  divided 
into  the  combination  of  both  swiftness  and  power.  In  acts  of 
muscular  swiftness  we  have  a  very  intimate  connection  between 
the  motor  center  and  the  muscular  mechanism,  in  which  the 
center  is  more  exercised  than  the  limbs  in  proportion  as  we  try 
to  produce  accuracy  of  movement  with  suddenness.  In  any  mus- 
cular action  involving  mere  power — as,  for  example,  lifting  a  dead- 
weight— there  is  very  little  effect  produced  upon  the  motor 
center,  but  the  strain  is  directly  upon  the  muscle  used,  collateral 
muscles  acting  with  this,  the  tendons  and  framework,  and  par- 


806       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

ticularly  the  heart  and  peripheral  vessels.  In  acts  which  involve 
both  force  and  swiftness  along  with  accuracy,  there  is  a  large 
complexity  in  the  physiologic  act,  and  a  most  wide-spread  strain 
is  thus  placed  upon  the  mechanism — as,  for  instance,  rowing  a 
boat  as  rapidly  and  as  long  as  possible.  There  is,  again,  another 
form  of  muscular  action  which  involves  a  very  considerable  strain, 
but  which  is  too  often  overlooked,  and  that  is  the  passive  phy- 
sical tension  illustrated  by  the  perfectly  strained  muscular  equi- 
poise of  a  cat  lying  in  wait  for  a  mouse,  in  which  almost  every 
muscle  of  the  body  is  used,  including  the  controlling  nervous 
mechanism  in  the  brain,  which  here  is  in  a  form  of  concentrated 
attention  (expectant  attention).  This  latent  energy  produces 
very  considerable  fatigue,  and  directly  in  proportion  to  the  degree 
of  excitement  and  concentration  of  attention.  It  is  familiar  to  all, 
and  most  of  us  can  appreciate  how  fatiguing  it  is  to  stand  for  a 
long  time,  or  to  hold  on  to  an  object,  as  even  a  baby  in  the  arms, 
the  tiller  of  a  boat,  or  the  reins  while  driving  a  horse.  The  strain 
is  doubled  by  an  excitement  which  may  again  be  emotionally  ex- 
aggerated to  the  hypersensitive  or  overconscientious  person  in 
the  performance  or  continuance  of  an  act.  It  is  not  so  familiar, 
perhaps,  but  equally  important,  to  realize  and  prevent  that  sort 
of  fatigue  which  is  liable  to  occur  in  those  who  must  remain  quiet, 
but  who  excite  themselves  by  subjectively  aiding  in  carrying  out 
conspicuous  acts  of  another  in  their  minds  while  watching  them. 
For  instance,  an  excitable  person  looking  at  a  match  game  of 
foot-ball,  influenced  by  eagerness  for  the  success  of  one  side, 
involuntarily  puts  forth  an  immense  degree  of  energy  by  his  de- 
sire to  help  along  the  others.  Indeed,  we  have  known  of  invalids 
who,  while  watching  such  contests  in  which  one  of  their  own 
family  was  contending,  became  seriously  exhausted  by  just  this 
sort  of  passive  strain  or  expectant  attention. 

There  is  a  distinct  physiologic  relief  produced  by  the  active 
forms  of  exercise  which  result  in  temporary  breathlessness  when 
followed  by  periods  of  rest.  Physical  and  mental  tension  is 
lowered  by  profuse  sweating  ;  excitement  is  relieved  to  a  great 
extent  by  a  normal  or  customary  overaccumulation  of  carbon 
dioxid,  which  is  itself  a  sedative. 

It  is  well  to  bear  in  mind  that  for  children  intrinsically  weak, 
both  in  their  muscles  and  in  their  nervous  force,  and  whose 
organs  are  also  below  the  average  power  of  their  other  parts, 
muscular  exercise  must  be  hedged  about  with  many  safeguards 
and  thoughtful  modifications.  It  is  doubtful  whether  such  chil- 
dren should  be  given  much  special  exercise  for  their  muscles 
alone,  such  as  by  pulley-weights,  dumb-bells,  and  gymnastic 


DEVELOPMENT    OF    THE    NEKVOX'S  SYSTEM.  8O7 

-  '-'  ..  up  Gil 

efforts,  unless  these  be  of  the  lightest  and  in  combination  with 
other  things,  while  it  is  equally  important  that  they  should  not 
be  allowed  too  large  a  scope  for  exercises  of  a  complex  nature. 
Deliberate  and  continued  acts,  of  which  carpentering  and  garden- 
ing are  familiar  types,  are  the  best.  Indeed,  the  use  of  tools, 
involving  as  it  does  interest  to  the  mind,  is  second  to  none  in 
value  for  young  or  old,  weak  or  strong.  Complex  exercises,  in- 
volving both  force  and  swiftness,  should  be  gradually  worked 
up  to.  The  most  perfect  form  of  gradual  approach  is  in  the 
form  of  regulated  exercises  devised  by  the  Swedes,  wherein  the 
muscular  acts  are  reduced  to  their  fundamental  principles  in  force 
and  direction  ;  and  in  the  hands  of  a  skilful  operator  a  person  is 
led  step  by  step  from  the  simplest  acts  to  the  most  complex  and 
forceful  ones,  and  during  this  process  the  organs  also  grow  accus- 
tomed to  the  gradual  strain.  When  the  individual  is  vigorous 
enough  to  perform  little  acts  of  skill,  incentive  is  thereby  added 
and  the  muscular  work  is  better  endured.  Later  on  minor  com- 
petitions have  their  place,  and  so  long  as  these  are  held  in  due 
restraint,  all  is  well,  and  great  benefit  results  from  a  judicious 
continuance.  If  incentive  becomes  insidiously  merged  into  ex- 
citement, then  a  peril  threatens.  Exciting  competitions  are  only 
for  the  strong  ;  innocent  incentive  in  the  form  of  music  during 
muscular  exercises  is  often  added  with  advantage.  This  is  par- 
ticularly illustrated  in  the  exercises  of  the  German  Turn-Verein 
and  Turn-Gemeinde. 

Dancing  is  a  most  wholesome  exercise,  if  only  it  be  not  super- 
added  to  or  grow  into  undue  excitement.  "Fancy  dancing" 
for  girls  is  of  special  value,  graduated,  of  course,  as  it  brings  out 
the  graces  as  well  as  strengthens  the  muscles,  teaches  equipoise, 
and  especially  benefits  the  loins  and  back,  the  weakest  places,  and 
usually  the  most  undeveloped  parts  in  females. 

Development  of  the  Nervous  System. — The  development 
of  the  nervous  system  has  points  of  similarity  to  the  growth  of 
a  bank  account,  and  is  subject  to  somewhat  the  same  variations  : 
at  times  inadequate,  again  fairly  sufficient,  on  extreme  occasions 
running  so  low  as  to  come  to  the  verge  of  being  overdrawn,  but 
under  no  circumstances  can  it  be  excessive  for  the  requirements 
of  the  child,  if  the  growing  needs  are  kept  in  mind.  Nervous 
force  grows  most  satisfactorily  by  slow  and  economic  degrees  ; 
excitements  of  all  sorts  are  perilous,  inducing  a  waste  in  one 
way  or  another,  and  only  robust  natures  accumulate  enough  to 
squander,  lest  peradventure  the  account  be  suddenly  overdrawn 
and  bankruptcy  ensue.  It  is  popularly  admitted  that  the  world 
is  swayed  by  vigorous  nerve  force.  Language  is  replete  with 


nC  3U 

MKTRS131 

808       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

terms  making  nervous  energy  synonymous  with  courage,  endur- 
ance, wisdom,  and  all  those  factors,  in  short,  which  are  embodied 
in  the  term  "success."  It  is  alone  the  lack  of  nervous  force 
which  sometimes  makes  inefficient  an  otherwise  sound  bodily 
organism.  On  the  other  hand,  a  feeble  construction,  endowed 
with  vigorous  nervous  force  and  energy,  constitutes  an  efficient 
engine.  An  adequate  accumulation  of  energy  in  the  nerve-cells 
and  centers  is  the  very  fountain  and  mainspring  of  a  wholesome 
life.  As  we  possess  little  or  much  of  this  are  we  useful  or  nega- 
tive beings  ;  whether  our  actions  are  mainly  mental  or  physical, 
it  is  the  same.  When  this  energy  is  exhausted  or  run  down,  it 
must  be  wound  up  again,  but,  unlike  the  clock,  it  requires  a  long 
period  of  time  in  accomplishment.  Moreover,  during  this  time 
all  the  vital  organs  tend  to  deteriorate  structurally  while  this 
controlling  force  is  withdrawn.  To  acquire  nervous  vigor  its 
growth  should  suffer  few  and  small  interruptions.  We  see 
among  country  folk,  laboring  men,  and  savages,  natures  which 
are  relatively  little  disturbed  by  protracted  drains  on  their  vitality, 
especially  of  the  kind  which  induces  physiologic  irritability  in 
more  complex  beings,  and  this  is  due  largely  to  their  slow  growth 
and  simplicity  of  life,  slowing  storing  up  cellular  energy.  Such 
folk  become  not  only  well  filled  with  force,  but  tenacious  of  it  and 
well  balanced.  If  their  store  is  suddenly  or  excessively  drawn 
upon,  they  can  well  sustain  the  tax.  Children  whose  lives  are 
passed  in  one  long  monotony  may  not  be  so  bright  and  alluring  as 
are  some  others,  but  they  are  far  more  stable,  and  better  able  to 
labor  and  endure.  Their  observation  is  simpler  and  slower,  but 
their  concepts  and  inferences  are  apt  to  be  clearer.  This  storing- 
up  of  vital  energy  should  begin  before  birth.  The  about-to-be 
mother  should  sacrifice  something  to  enable  her  to  live  quietly 
and  heathfully.  A  vast  deal  of  harm  would  be  avoided,  as  well 
as  trouble  to  the  mother  and  anxieties  for  her  child,  if  this 
prenatal  period  could  be  spent  under  natural  and  wholesome 
conditions.  We  have  scarcely  begun  to  know  much  about 
maternal  impressions,  but  they  are  of  deeper  influence  and  sig- 
nificance than  can  yet  be  explained.  Hurtful  impressions  are 
thus  transmitted  beyond  a  doubt,  and  beneficent  ones  even  more 
truly  and  constantly.  It  is  conceded  that  the  finest  known 
specimens  of  children  are  found  among  the  British  nobility,  and, 
as  has  been  said  elsewhere  in  this  volume,  our  insular  cousins 
are  more  enduring  than  we,  certainly  in  physical  competitions, 
as  in  long-distance  running.  The  conditions  of  their  early 
growth  and  development  are  hedged  about  with  unusually  wise 
safeguards.  If,  as  has  been  objected  by  sentimental  observers, 


DEVELOPMENT    OF    THE    MIND.  809 

these  children  see  less  of  their  parents  than  those  of  humbler 
folk,  they  are  provided  with  the  best  possible  substitutes  in  the 
way  of  caretakers  and  teachers.  They  are  reared  under  the 
most  perfect  conditions  as  to  surroundings,  almost  altogether 
in  country  places  ;  whereas  those  children  compelled  to  live  with 
their  parents — who,  having  a  good  many  demands  upon  them, 
are  unable  to  devote  their  best  energies  to  the  care  and  instruc- 
tion of  their  offspring — are  liable  to  grow  up  haphazard,  and 
fall  into  many  dangers,  in  spite  of  the  best  affection  and  inten- 
tions. Indeed,  there  is  a  manifest  peril  for  a  child  to  be  provided 
with  too  much  or  too  solicitous  affection  from  unwise  parents, 
and  although  home  influences  are  inestimable  in  the  way  of 
character  growth,  nevertheless  the  exigencies  of  modern  life  too 
often  call  away  the  best  energies  of  the  parents,  and  children 
come  in  for  what  is  left. 

A  word  may  be  said  in  passing  of  children  who  are  backward 
mentally,  a  condition  which  frequently  is  only  relative,  being  a 
state  of  instability  of  the  nervous  equilibrium,  from  which  good 
or  evil  results  may  follow,  depending  upon  the  same  conditions 
which  help  or  prevent  the  growth  of  the  nervous  force  in  the  body 
elsewhere.  By  far  the  most  important  considerations  have  to  do 
with  the  acquirement  of  physical  invigoration.  If  mental  feeble- 
ness is  once  recognized,  it  is  beyond  measure  important  for  the 
parents  to  seek  skilful  advice  and  to  follow  it  closely.  The  edu- 
cation of  the  mind  and  of  the  body  should  go  hand  in  hand, 
and  all  forced  forms  of  mental  training  should  be  avoided.  If 
the  parent  is  able  and  willing  to  be  the  caretaker,  and  spend  a 
good  deal  of  time  in  the  open  air,  especially  the  fields  and  barn- 
yard, thus  insidiously  teaching  and  molding  both  mind  and  body, 
sharpening  observation,  and  aiding  in  the  formation  of  clear 
mental  concepts,  immense  good  can  be  accomplished,  and,  not 
seldom,  the  prevention  of  serious  mental  warping. 

Development  of  Mind. — It  is  important  that  a  few  remarks 
be  made  on  the  development  of  mind  as  tending  to  show  the 
connection  which  the  brain  and  its  processes  have  with  enfeebled 
bodies.  We  occasionally  see  precocious  minds  endowed  with 
very  feeble  envelops.  If  such  brains  are  overencouraged,  they 
are  capable  of  using  up  too  readily  what  little  residual  vigor 
there  is  in  the  entire  organism.  Precocity  is  a  manifest  peril  ;  * 
it  is  ever  of  doubtful  value  ;  the  very  abnormality  is  evidence 

*  Precocity  is  a  loss  of  balance  between  the  bodily  and  mental  growth  of  children 
in  which  one  or  the  other  element  may  predominate,  but  rarely  both  appear  together. 
This  state  is  scarcely  one  for  parental  gratulation,  and  always  demands  exceptional 
care  to  check  on  the  exuberant  hand  and  develop  on  the  lacking  side.  It  is  seldom 


8lO       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

which  should  put  us  on  our  guard,  so  that  we  should  aid  in  pre- 
serving not  only  the  organic  activities  and  groundwork,  but, 
above  all,  the  integrity  of  the  mind  itself.  Other  things  being 
equal,  the  mind  should  receive  little  or  no  special  attention  until 
the  rest  of  the  organism  is  fairly  well  repaired  and  put  in  working 
order.  Actual  instruction  had  better  be  delayed,  and  the  teach- 
ing should  always  begin  with  the  simplest  possible  object-lessons  ; 
suggestions  such  as  emanate  from  well-conditioned,  wholesome- 
minded  folk  should  surround  the  child,  even  then  keeping  very 
close  to  simple,  uncomplicated  truths  and  their  practical  applica- 
tion. The  method  of  teaching  as  outlined  by  that  wise  and  good 
man,  Froebel,  is  the  healthiest  both  for  the  weak  and  the  strong, 
and  no  system  has  ever  been  devised  which  approaches  it  in 
wholesomeness,  certainly  for  very  young  children.  Along  with 
physical  weakness  there  is  inevitably  a  certain  lack  of  mental 
vigor,  and  this  must  be  particularly  borne  in  mind,  no  matter 
how  intelligent  or  bright  a  child  may  seem  to  its  admiring  parents 
or  worshiping  relatives.  Mental  processes  are  purely  the  out- 
come of  physical  activities,  and  there  are  in  history  conspicuous 
instances  of  great  intelligence,  and  possibly  wisdom,  pointed  out 
as  existing  in  wretchedly  undeveloped  bodies  ;  yet  such  are  always 
open  to  question,  and  in  the  ordinary  course  of  every-day  life  we 
certainly  can  not  assume  that  this  unnatural  juxtaposition  is  prob- 
able. Therefore  it  must  be  assumed  from  the  outset  that  in  a 
feeble  body  the  mind  must  be  handled  with  unusual  delicacy  and 
judgment  to  enable  it  to  develop  according  to  its  possibilities,  no 
matter  how  highly  or  hopefully  we  estimate  these.  At  least,  the 
regularity  of  the  organic  activities  must  be  fairly  good  to  enable 
a  structure  of  such  astounding  delicacy  as  the  brain  to  grow  natur- 
ally in  size  and  power,  and  there  must  be  maintained  a  very 
high  order  of  cellular  integrity  to  enable  that  organ  to  reach  even 
a  fair  degree  of  energizing  capacity  and  delicate  differentiation. 
If  this  is  true  of  early,  budding  infancy,  when  the  whole  organ- 
ism is  largely  that  of  a  vegetable,  and  until  the  time  of  early 
adolescence,  when  the  brain  reaches  its  normal  bulk,  it  is  even 
more  important  that  from  that  time  on  to  maturity,  which  is 
about  the  twenty-fifth  year,  every  care  be  exercised  to  enable  the 
normal  perfection  to  be  reached.  When,  then,  instruction  shall 
be  admissible  for  a  little  one  is  a  matter  of  much  difficulty  to  de- 
cide, and  just  how  much  and  of  what  sort  this  shall  be  depending, 

or  never  accompanied  by  intellectual  balance.  A  capacity  for  sustained  action,  mental 
or  physical,  is  unusual  also,  and  in  many  ways  such  children  are  disturbing  factors  to 
their  families  and  themselves,  and  usually  come  to  ultimate  grief.  They  need  isolation 
and  systematic  physical  development  of  a  slow  and  quiet  kind. 


FEEBLENESS  IN  GIRLS  ABOUT  THE  AGE  OF  PUBERTV.    8ll 

of  course,  upon  the  material  with  which  one  has  to  build.  How- 
ever, the  ordinary  method  of  teaching  language,  dividing  it  up 
into  letters  and  constructed  words,  leading  thence  to  the  princi- 
ples of  language,  and  finally  to  abstract  thought,  clothed  too 
often  in  almost  incomprehensible  phrase,  is  certainly  far  from 
wholesome  for  those  of  the  weaker  sort. 

Simple  inductive  reasoning  from  natural  objects,  of  their 
quality,  habits,  and  means  of  growth,  is  the  kind  of  teaching 
that  should  be  pursued.  The  average  teacher  knows  pitiably 
little  about  what  the  mind  of  man  in  this  budding  state  is  capa- 
ble of  doing.  We  would  urge  upon  all  who  have  any  desire  to 
know  the  truth  to  begin  by  learning  what  the  ordinary  concepts 
of  a  young  child  are  and  how  they  shape  themselves,  and  how 
language,  as  ordinarily  learned  by  him,  so  misleading,  is  capable 
of  conveying  or  distorting  thought. 

FEEBLENESS     IN    GIRLS    ABOUT    THE    AGE    OF 

PUBERTY. 

Girls  who  become  pallid  and  feeble  about  the  time  of  puberty 
constitute  a  more  or  less  constantly  recurring  group  of  cases, 
and  present  themselves  with  a  series  of  symptoms  indicating 
symmetric  enfeeblement  of  mind  and  body,  becoming  lackluster, 
losing  interest  in  life,  and  are  a  source  of  considerable  anxiety 
to  their  parents.  Too  often  this  group  of  symptoms  escapes  the 
attention  it  deserves  ;  a  medical  adviser  trying,  perhaps,  several 
methods  to  relieve  and  failing,  gives  the  time-serving  advice  to 
allow  this  child  to  outgrow  the  difficulty.  Of  course,  if  any 
organic  disturbance  is  detected  ;  if  there  is  anything  obviously 
amiss  in  the  digestion  or  elsewhere,  and  these  difficulties  are  re- 
moved, then  in  the  removing  of  that  which  is  obvious  other  dis- 
ordered states  are  helped,  and  final  recovery,  partial  or  complete, 
may  be  the  result. 

So  long  as  girls  are  in  the  vegetative  stage,  with  undeveloped 
sexual  tendencies,  while  they  romp  and  play  as  boys  and  girls 
should  do,  all  goes  well.  The  requirements  of  civilized  society, 
consciously  or  unconsciously  recognized,  which  limit  the  too 
boisterous  play  of  girls,  causing  this  to  stop  or  offering  discour- 
agement, inducing  an  early  oversqueamishness  about  getting 
themselves  dirty,  or  making  more  noise  than  custom  encourages, 
taking  more  interest  in  the  refinements  of  life  than  the  essentials, 
gradually  produce  in  girls  approaching  puberty  an  exaggerated 
sense  of  the  importance  of  refined  conduct.  This  is  by  no  means 
confined  to  the  upper  class,  although,  perhaps,  more  generally 
seen  there. 


8l2       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

Often  very  early  the  human  female  begins  to  suffer  from  slowly 
acting  bowels ;  not  only  so,  but  unless  the  opportunity  for 
evacuating  these  is  hedged  about  with  all  kinds  of  artificial  safe- 
guards, any  discouragement  will  result  in  neglect.  Teachers  in 
schools  admit  this  when  differences  between  boys  and  girls  in 
this  particular  are  pointed  out. 

An  examination  of  the  girl  who  seems  to  have  lost  her  interest 
in  life  will  usually  reveal  loss  of  appetite  or  overparticularity  in 
choosing  of  foods,  often  some  vitiation  of  tastes,  lack  of  muscular 
capacity,  perhaps  some  evidence  of  dyspnea  on  exertion,  irregular 
or  slow-acting  bowels  or  recognizable  failure  in  circulatory 
activities,  especially  clammy  hands  and  feet,  heaviness  of  breath, 
and  if  the  lungs  are  examined,  the  apices  are  seen  to  be  insuffi- 
ciently expanded.  The  heart  exhibits  evidence  of  dilatation,  or, 
at  any  rate,  there  is  a  flabbiness  about  it  and  a  distance  to  its 
sounds,  a  heaving  impulse,  and  the  pulse  becomes  overreadily 
disturbed  in  rhythm  upon  motion  or  excitement. 

The  girl  will  be  more  inclined  to  read  and  employ  herself  in 
sedentary  fashion,  and  will  lack  spontaneous  activity  and  alert- 
ness. The  blood,  if  examined,  will  be  found  defective  in  hemo- 
globin ;  the  urine  perhaps  of  the  highest  specific  gravity,  probably 
alkaline,  or,  it  may  be,  considerably  increased  in  amount,  or 
these  conditions  may  alternate.  The  symptoms  are  vague 
enough  to  escape  attention  ordinarily,  but  prompt  and  persistent 
remedies  are  here  of  almost  as  much  importance  as  in  more 
seriously  disturbed  states.  If  all  this  is  neglected,  the  girl's 
character  may  sometimes  be  grievously  altered  and  her  future 
changed.  She  may  be  regarded,  however,  as  merely  quieting 
down  from  her  hobbledehoy  stage,  and  many  mothers  will 
usually  welcome  this. 

Remedial  measures  are  most  important,  lest  worse  things 
follow,  and  should  be  persistently  employed  for  months  rather 
than  weeks,  continued,  it  may  be,  for  years.  Nothing  is  of 
more  importance  than  that  the  physician  shall  gain  the  confidence 
of  his  patient  and  secure  her  cooperation.  If  she  will  be  frank 
and  candid  in  discussing  the  matter  with  him,  he  will  very  often 
find  much  that  would  otherwise  remain  obscure.  There  are 
numerous  psychic  conditions  which  demand  careful  weigh- 
ing— the  doubts,  the  fears  or  ambitions,  more  likely  a  hyper- 
critical self-examination  ;  at  any  rate,  an  increased  introspection, 
and  not  seldom  a  rather  interesting  and  original  conception  or 
expression  of  views  on  life  which  will  amuse  and  instruct  the 
investigator. 

The  chief  difficulties  and  needs  have  to  do  with  the  question 


FEEBLENESS    IN    GIRLS    ABOUT    THE    AGE    OF    PUBERTY.        813 

of  supplying  incentive,  the  devising  how  to  secure  an  increased 
interest  in  life  in  its  wholesomer  aspects.  Lack  of  incentive 
is  the  greatest  stumbling-block  in  dealing  with  apathetic  folk, 
whether  children  or  adults,  and  here  the  personal  factor,  the 
force  and  individuality  of  the  physician,  comes  in  most  strongly, 
and  some  men  can  infuse  a  greater  degree  of  enthusiasm  into 
their  patients  than  others. 

As  to  how  we  shall  accomplish  initial  movements,  an  awaken- 
ing of  interest  and  invigoration  of  the  will,  few  rules  can  be 
outlined  or  defined.  It  is  a  good  plan,  however,  to  strive  earn- 
estly to  impress,  not  only  the  necessity  of  doing  as  we  direct, 
but  to  urge  this  with  such  subtlety  and  tact  and,  withal,  extreme 
persistence  and  variety  in  our  methods,  that  the  result  may  be 
surely  obtained  soon  or  late.  Flattery  is  an  important  agent, 
stirring  the  vanity  which  every  one  possesses,  or  should  possess, 
and  it  is  perhaps  nowhere  more  influential  than  in  dealing  with 
girls,  for  the  key-note  of  success  lies  here.  Of  course,  it  is  im- 
possible to  expect  much  success  in  shaping  or  directing  forces 
until  there  is  enough  of  inherent  vigor  present  to  warrant  activi- 
ties, whether  of  the  mind  or  body. 

The  first  organ  to  be  looked  to  is  the  heart,  not  neglecting,  of 
course,  the  digestive  conditions.  A  powerful  heart  tonic  used 
for  a  few  days  or  weeks  will  help  more  than  any  other  one  medi- 
cine, and  it  is  our  custom  to  add  to  any  tonic  used  digitalis 
(digitalin)  or  strophanthus  or  nux  vomica  in  full  doses.  So  soon 
as  we  can  secure  a  full,  regular,  strong  pulse,  and  one  which  is 
not  subject  to  more  than  the  normal  variations  from  lying,  sitting, 
or  standing,  and  swift  movements,  we  have  the  most  important 
physical  point  gained.  The  amount  and  character  of  the  anima- 
tion are  fair  indications  of  the  usefulness  of  our  heart  tonics  ; 
the  urination  is  also  a  helpful  index,  and  these  should  be  reduced 
to  uniformly  demonstrable  measures. 

The  digestion  requires  assistance,  and  the  predigesting  agents, 
such  as  pepsin  or  pancreatin  in  elixir,  are  not  only  of  value,  but 
good  menstrua  for  other  drugs.  The  bowels  must  be  kept 
sufficiently  active.  The  food  should  be  supplied  in  adequate 
amount,  using  exact  measurements,  and  had  better  be  highly 
albuminous,  at  least  for  a  time.  There  is  usually  little  appetite 
for  meat,  and  often  revolt  at  milk.  Regulated  amounts  of 
broiled  or  scraped  beef  or  mutton,  along  with  predigested  milk 
or  koumiss,  will  soon  show  results.  Along'  with  the  digestive 
tonic  it  is  well  to  use  mineral  acids,  muriatic  or,  preferably,  nitro- 
muriatic,  especially  where  the  urine  is  found  to  be  alkaline — a 
very  common  factor  of  mental  depression.  Most  cases  of  ane- 


8  14       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

mias  in  this  class,  as  well  as  in  younger  children,  are  due  to  faults 
in  the  intestinal  digestion,  and  important  medicines,  aside  from 
those  alluded  to,  are  forms  of  myrrh,  such  as  aloes  and  myrrh, 
and  the  intestinal  antiseptics,  salol,  benzonaphthol,  and  bismuth  ; 
sometimes  the  use  of  castor  oil,  either  once  or  twice  a  week  at 
first,  to  secure  thorough  evacuation,  or  in  smaller  amount  in  cap- 
sule three  times  a  day,  immediately  before  meals,  in  ten-  to 
twenty-minim  doses,  is  very  helpful  in  catarrhal  states. 

Many  girls  get  into  the  luxurious  habit  of  sponging  themselves 
piecemeal,  in  driblets  of  lukewarm  water,  or  taking  a  warm  or 
hot  bath,  which  they  declare  is  a  great  comfort  and  pleasure.  It 
is,  of  course,  not  wise  to  insist  on  a  cold  bath  at  once,  especially 
where  menstruation  is  irregular,  but  this  can  be  accomplished  by 
the  help  of  a  competent  trained  assistant  or  a  good  nurse  or 
maid.  The  use  of  cold-water  sponging  or  bathing  should  be 
learned  and  practised.  A  good  way  to  begin  is  this  :  Let  the 
patient  stand  in  about  three  inches  of  warm  water  ;  get  a  maid 
to  sponge  her  off  in  a  little  of  this,  immediately  following  with  a 
larger  sponge,  rapidly  going  over  her  with  cool  salt  water,  grow- 
ing colder  each  day  until  it  is  quite  as  cold  as  the  room  in  which 
she  stands,  or  more  so  ;  follow  immediately  by  a  brisk  rub-down, 
until  the  skin  acquires  a  prompt  reaction,  and  there  comes  a 
clear  pink  color  from  head  to  heel.  This  bath,  in  the  event 
of  marked  weakness  or  if  it  be  followed  by  exhaustion,  is  better 
given  after  a  partial  breakfast,  such  as  a  cup  of  cocoa,  and  fol- 
lowed by  rest  in  bed  for  half  an  hour,  then  the  bath  given  by  a 
maid,  a  rough  rub-down  follows,  and,  finally,  breakfast.  As  the 
girl  grows  stronger  she  will  take  her  cold  bath  herself  and  learn 
to  enjoy  it.  It  is  valuable  also,  after  some  regular  outing  or  ex- 
ercise, to  take  another  salt  sponging,  not  so  thorough,  perhaps, 
or  a  brisk  rub-down,  and  a  rest,  lying  down  from  half  to  an 
hour,  say,  until  the  end  of  the  afternoon  and  until  the  evening 
meal  is  ready. 

The  kind  of  exercise  suitable  to  such  cases  is  too  large  a  sub- 
ject to  discuss  in  full.  One  thing  is  manifest :  the  habitual  inac- 
tion reacts  upon  the  heart,  increasing  its  feebleness,  from  what- 
soever cause  that  may  have  come.  A  slowly  and  carefully  in- 
creased exercise,  not  too  monotonous,  along  with  vigorous  tonic 
medication,  will  repair  the  fountains  of  motor  force. 

The  lungs  will  usually  be  found  insufficiently  expanded,  at  the 
apex  especially,  and  respiratory  gymnastics  are  indicated  if  some 
one  can  be  found  to  direct  them  properly,  and  this  the  physician 
himself  should  supervise.  Forced  deep  breathing,  with  a  few 
forced  stretchings  of  the  arms,  twice  or  thrice  a  day,  will  ac- 


FEEBLENESS  IN  GIRLS  ABOUT  THE  AGE  OF  PUBERTY.    815 

complish  needed  expansion  and  greatly  aid  in  oxygenating 
the  blood.  The  use  of  medicated  inhalations  is  helpful,  or  the 
use  of  whatever  agencies  will  produce  a  deep,  full  respiratory 
action.  At  first  the  patient  will  complain  that  it  makes  her 
dizzy,  and,  being  more  or  less  apprehensive  about  her  physical 
state,  she  will  object.  So  soon  as  she  can  be  induced  to  take 
mild  open-air  exercise  (of  which  walking  solemnly  along  the 
street  is  emphatically  not  the  best  and  not  even  a  good  form),  she 
had  best  be  encouraged  to  do  so.  The  so-called  calisthenic  ex- 
ercises, which  mean  "  beautiful  forcefulness,"  probably  because 
they  are  usually  so  hideous,  are  devoid  of  interest  and  not  par- 
ticularly useful.  Only  that  exercise  is  best  which  involves  some 
pleased  acquiescence  in  the  performer  or  some  interest  in  the 
doing.  Fancy  dancing,  as  previously  remarked,  admirably  de- 
velops loins  and  back. 

Tennis  is  also  very  well,  but  too  violent  for  girls  below  par,  and 
certainly  until  the  patient  gets  into  a  moderately  good  condition. 
Golf  is  one  of  the  best  possible  exercises  and  is  to  be  highly 
and  persistently  recommended.  It  can  be  played  at  any  time, 
for  any  length  of  time,  alone  or  in  company.  A  giant  may  play 
even  with  a  dwarf  by  handicapping.  The  bicycle  has  the  very  pro- 
found merit  of  being  acceptable  to  most  persons,  at  least  nowa- 
days, while  it  is  still  generally  used  ;  it  may  not  be  the  best  thing 
to  use,  but  it  is  certainly  best  to  use  something  that  is  not  harmful, 
and  in  most  cases  this  fills  a  very  obvious  need.  The  bicycle  is 
monotonous,  and  the  character  of  movements  is  restricted  by  the 
rotary  mechanism,  hence  it  develops  unsymmetrically  and  may 
exhaust  before  tiring  the  muscles.  Cycling  is  a  peril  because  of 
the  competition  of  companions  who  lure  the  weak  ones  too  far. 
Girls  should  not  push  up  steep  hills  and  never  attempt  to  keep 
pace  with  powerful  young  men.  The  strain  on  the  eyes  often  gives 
headaches  ;  constant  unremitting  balance  also  fatigues  ;  both  to- 
gether cause  migraine  frequently.  Swimming  at  the  seashore  or 
elsewhere  is  of  admirable  efficacy.  Rowing  gently  in  a  skiff; 
the  old-fashioned  game  of  croquet,  most  unfortunately  now  out  of 
fashion  ;  the  excellent  and  ancient  game  of  graces,  which  really 
was  more  or  less  graceful  ;  and  that  obsolete  practice  known  as 
battledore  and  shuttlecock — all  have  merit.  For  those  who  can 
afford  it,  or  in  whom  it  is  warranted,  it  is  certainly  best  to  pre- 
scribe and  supervise  a  course  of  massage  and  regulated  exercises 
in  the  form  of  specially  prescribed  movements  ;  but  the  discussion 
here  has  rather  to  do  with  cases  who  do  not  care  to  be  considered 
invalids,  yet  none  the  less  require  the  full  attention  of  physician 
and  parent. 


8l6       GENERAL  CONSIDERATIONS  ON  PHYSICAL  DEVELOPMENT. 

Girls  who  go  to  school  are  the  victims  in  these  days  of  vaguely 
defined  forms  of  exercise  called  "physical  culture,"  usually  dem- 
onstrated by  one  of  the  least  busy  of  the  teachers,  who  tells  them 
to  stand  up  and  wave  their  arms  to  a  one,  two,  three  order,  and  the 
uninterested  girls  present,  under  these  circumstances,  acquire  a 
most  listless,  imbecile  expression.  But  this  is  better  than  nothing, 
— better  by  far  than  sitting  all  day  stagnating, — and  may  serve  a 
more  or  less  useful  turn.  Under  the  direction  of  a  qualified 
teacher  posing,  stretching,  bending,  and  tension  exercises  are 
of  incalculable  value.  If,  however,  the  time  so  used  were  em- 
ployed in  tossing  back  and  forth  a  good  old-fashioned  bean- 
bag  from  one  to  another,  or  that  most  useful  of  exercises,  the 
medicine  ball,  causing  it  to  make  the  circuit  of  the  room,  and 
omitting  no  one  ;  perhaps  keeping  two  or  three  going,  giving  eye 
and  hand  and  brain  all  an  opportunity  of  acting  together,  and  in- 
volving, as  it  does,  some  little  amusement  of  a  competitive  kind, 
and  requiring  some  personal  nimbleness  and  skill,  would  be  the 
best  employment  for  the  short  recess  in  the  ordinary  girls'  school. 
When  the  weather  admits  of  it,  the  best  thing  to  do  would  be  to 
don  overshoes  and  warm  head-gear,  a  pair  of  old  gloves,  and  toss 
this  medicine  ball  about  out-of-doors.  But  if  this  be  objectionable 
to  the  oversqueamish  teacher  or  parent,  let  the  windo'ws  be  opened 
wide  and  the  girls  kept  at  exercise  for  ten  minutes  pretty  actively  ; 
they  would  thus  get  a  mouthful  of  clean  air  and  a  stirring-up  of 
the  blood,  with  absolutely  no  danger  of  "  catching  cold."  It  is, 
indeed,  one  of  the  most  difficult  problems  first  to  select  and  next 
to  carry  out  the  proper  means  of  developing  the  bodies  of  our 
growing  girls.  The  subject  is  woefully  neglected,  although  there 
are  a  good  many  fashionable  attempts  made,  and  the  results  are, 
in  a  measure,  satisfactorily  growing.  There  is  much  to  be  said 
in  favor  of  the  so-called  relaxing  exercises,  when  skilfully  taught 
by  one  who  can  elicit  some  interested  cooperation,  accompanied, 
it  may  be,  by  music,  and  supplemented  by  posings  and  graceful, 
rhythmic  stretchings  and  deep,  regulated  breathings.  Class 
work  is  of  value  as  sustaining  interest  and  attention.  The  best 
teaching  is  in  private,  by  a  mistress  of  the  art,  who  will  judiciously 
increase  and  vary  the  movements  in  accordance  with  individual 
needs. 

One  word  should  be  said  just  here  about  the  various  disturb- 
ances of  regular  menstruation  when  once  established.  These  are 
very  rarely  due  to  any  malposition  of  the  uterus.  The  colicky 
pains,  backaches,  nausea,  etc.,  are  seldom  more  than  the  outcome 
of  incomplete  or  irregular  development  in  the  uterine  tissues,  the 
local  circulatory  supply,  or  the  nervous  distribution,  all  of  which 


FEEBLENESS    IN    GIRLS    ABOUT    THE    AGE    OF    PUBERTY.        8 1/ 

maybe  slow  to  adjust  themselves  to  new  and  complex  conditions. 
Most  disturbances  of  the  organs  of  generation  in  women,  as  the 
wiser  gynecologists  admit,  are  sequences  of  coition  and  preg- 
nancies, partial  or  complete,  or  specific  infection,  or  both — neo- 
plasms excepted.  Pelvic  examinations  can  be  predicted  to  be 
negative,  and  should  only  be  practised  when  all  other  rational 
measures  fail.  These  consist  of  due  attention  to  the  whole 
organism  and  systematization  of  special  hygienic  measures,  as 
already  outlined.  But  let  it  not  be  forgotten  that  once  the  atten- 
tion of  a  neurotic  girl  is  directed  to  her  pelvic  organs,  her  mind 
becomes  infected  with  a  germ  of  disease  which  may,  and  too 
often  does,  warp  her  life  and  that  of  all  those  in  her  immediate 
environment. 


CHAPTER  XIX. 

CONDITIONS  REQUIRING  SURGICAL  PRO- 
CEDURES. 


LYMPHADENITIS. 
Synonym. — LYMPHANGITIS. 

Inflammations  of  the  lymphatic  glands  are  of  great  clinical 
importance  and  not  very  simply  classified  as  yet ;  they  may  be 
acute,  chronic,  or  tuberculous. 

These  glands  are  so  situated  that  they  act  as  sentinels  to  the 
circulatory  system,  and,  being  endowed  with  bactericidal  power, 
they  have  the  power  of  destroying  or  neutralizing  poisons,  and 
it  is  only  by  the  overwhelming  numbers  of  bacteria  being  ab- 
sorbed that  they  themselves  become  affected,  for,  according  to 
recent  investigations,  inflammation  of  the  lymphatic  glands  is 
caused  by  the  absorption  of  some  form  of  bacteria  or  toxin,  in- 
variably from  a  more  or  less  distant  focus — that  is,  from  with- 
out. The  axillary,  inguinal,  cervical,  bronchial,  and  mediastinal 
glands  are  the  ones  most  frequently  affected. 

ACUTE  LYMPHADENITIS. 

Definition. — Acute  inflammation  of  the  lymphatic  glands. 

Causes. — The  most  common  causes  of  inflammation  of  the 
glands  are  the  eruptive  and  infectious  diseases,  as  scarlet  fever, 
diphtheria,  and  septic  wounds,  diseases  of  the  teeth,  etc.  The  face 
and  neck,  being  largely  exposed  to  slight  traumatism  and  pro- 
tected by  a  thin  epithelium,  furnish  a  fertile  infection  atrium. 

Pathology. — A  lymph-node  is  the  first  filtration  station 
against  the  invading  micro-organisms,  and  in  many  instances  it  is 
altogether,  or  again  only  in  part,  able  to  repel  the  attack.  Fail- 
ing in  this,  a  chain  of  glands  becomes  infected,  the  degree  of 
damage  is  in  proportion  to,  being  modified  by,  the  inherent 
resisting  power  of  the  individual.  In  acute  inflammation  the 
gland  becomes  intensely  vascular,  with  free  exudation ;  the 

818 


LYMPHADENITIS.  8  I  9 

escaping  leukocytes  there,  as  well  as  those  in  the  lymph  coming 
from  the  primary  focus,  are  retained  and  accumulate  in  the  gland 
until  it  is  impossible  to  recognize  the  cortex  from  the  medulla. 
By  removing  the  cause  the  process  gradually  subsides,  the  new 
elements  undergo  disintegration  and  absorption,  and  the  gland 
returns  to  its  natural  condition  (resolution)  or  may  remain  chron- 
ically enlarged.  If  the  process  goes  on  to  suppuration,  the 
trabeculae  of  the  gland  are  destroyed  and  the  loculi  become  filled 
with  pus,  and  the  surrounding  connective  tissue  becomes  inflamed 
and  suppurates. 

Symptoms. — General  symptoms  are  usually  slight,  depend- 
ing upon  the  severity  of  the  cause.  Local  symptoms  are  pain, 
heat,  swelling  of  the  gland  or  glands  ;  the  skin,  as  a  rule,  is  not 
affected.  If  the  periglandular  tissue  is  not  involved,  upon  ex- 
amination there  will  be  found  a  well-defined  tumor,  hard,  elastic, 
and  movable.  If  the  pain  and  swelling  become  less  and  gradu- 
ally disappear,  resolution  results  ;  if,  on  the  other  hand,  the  pain 
and  swelling  increase,  the  skin  becoming  red  and  edematous,  the 
tumor  immovable,  and,  instead  of  being  hard  and  elastic,  it  is 
soft  and  fluctuating,  we  know  that  suppuration  has  taken  place, 
usually  accompanied  by  a  chill  and  rise  of  temperature. 

Diagnosis. — Diagnosis  is  usually  easy  ;  as  we  have  seen, 
adenitis  is  invariably  caused  by  some  external  source  of  irrita- 
tion, except  in  cases  of  deep-seated  or  visceral  adenitis,  when 
sometimes  it  is  impossible  to  determine  the  source  of  infection. 

Prognosis  is,  as  a  rule,  favorable,  except  where  there  is  ex- 
tensive suppuration,  especially  in  the  neighborhood  of  important 
organs  and  vessels. 

Treatment. — Our  first  step  in  the  treatment  is  to  seek  for 
and  to  try  to  remove  the  primary  cause. 

Local  Treatment. — Absolute  rest  of  the  part  affected  is  indi- 
cated, along  with  the  applications  of  cold  (cold-water  compress), 
antiseptic  solutions,  as  bichlorid  of  mercury,  I  :  2000  or  4000, 
a  mercurial  or  ichthyol  (25  per  cent.)  ointment,  or,  if  it  can  be 
borne,  slight  compression  ;  the  interglandular  injection  of  carbolic 
acid.  It  is  important  to  secure  resolution  if  possible,  as  many 
changes  of  a  reparative  and  protective  character  take  place 
among  the  blood-cells. 

Electricity — the  continuous  current — has  been  used  with  fairly 
good  results,  daily  sittings  of  ten  minutes  of  from  five  to  fifteen 
milliamperes.  Constitutional  treatment  should  not  be  neglected, 
and  should  be  especially  supporting.  A  free  saline  purge  at 
the  onset  is  often  most  beneficial. 

When  suppuration  is  plainly  evidenced,  a  free  incision  should  be 


82O  CONDITIONS    REQUIRING    SURGICAL    PROCEDURES. 

made,  and  the  cavity  then  washed  out  with  peroxid  of  hydrogen  or 
other  antiseptic  solutions  and  packed  with  gauze  ;  when  persistent 
and  stubborn,  the  cavity  had  best  be  curetted,  or,  should  a  fistula 
form,  then  curetment  is  necessary.  If  this  proves  unsuccessful, 
it  should  be  laid  open. 

CHRONIC  ADENITIS. 

Chronic  adenitis  may  follow  the  acute  form,  or  the  disease  may 
be  chronic  from  the  beginning,  and  while  it  is  not  necessarily 
tuberculous,  in  the  large  majority  of  cases  it  becomes  so. 

Etiology. — Simple  chronic  adenitis  begins,  like  the  simple 
acute  form,  in  some  point  of  infective  invasion  from  without,  such 
as  chronic  skin  troubles,  ingrown  toe-nails,  caries  of  the  teeth, 
producing  inflammation  at  or  around  the  roots.  The  infective 
material  may  remain  dormant  in  a  gland  after  the  disease  process 
at  the  point  of  invasion  has  been  cured,  and  yet  from  some  slight 
cause  the  poisons  may  again  become  active. 

Pathology. — In  simple  chronic  adenitis  the  reticular  structure 
becomes  thicker  and  more  fibrous,  the  lymph-cells  diminish  in 
number,  the  gland  becoming  hard  and  fibrous.  In  the  first  stages 
of  a  tuberculous  gland,  as  a  rule,  it  is  redder  than  usual,  though 
sometimes  it  may  be  gray  and  somewhat  translucent. 

The  tuberculous  granules  are  made  up  from  the  vascular  and 
lymphatic  vessels  found  in  the  cortical  and  medullary  portions  of 
the  gland.  Caseation  rapidly  develops  in  them,  and  is  due  to 
vascular  obliteration. 

When  caseation  is  established,  almost  all  of  the  bacilli  have 
disappeared,  but  the  spores  remain,  which  are  capable  of  repro- 
ducing the  disease.  The  presence  of  the  bacilli  is  rarely  demon- 
strable in  the  product  of  the  glands,  but  when  guinea-pigs  are 
inoculated  with  the  pus,  they  readily  become  affected  with  tuber- 
culosis. Tuberculous  adenitis  may  be  a  local  disease,  under- 
going spontaneous  resolution,  but  so  long  as  the  focus  is  present 
it  constitutes  a  menace  to  the  system. 

Symptoms. — Swelling,  which  may  develop  gradually  or  re- 
main from  an  acute  attack,  no  pain,  no  redness  of  skin,  movable, 
.but  may  in  time,  through  peri-adenitis,  become  glued  to  the  skin, 
especially  if  more  than  one  gland  is  affected. 

The  symptoms  may  be  divided  into  three  stages  :  First,  that 
of  induration  or  indolence  ;  second,  that  of  inflammation  ;  third, 
that  of  suppuration. 

The  first  stage  may  last  for  years  ;  the  glands  are  hard  and 
elastic.  In  the  second  stage  they  take  on  activity,  becoming 
painful  and  tender,  with  more  or  less  redness  of  the  skin. 


LYMPHADENITIS.  821 

In  the  third  stage  the  gland  softens,  the  skin  ulcerates  through, 
and  the  contents  of  the  gland,  a  caseous  matter  mixed  with  a 
whitish,  watery  fluid,  is  evacuated  ;  the  resulting  cicatrices  are 
adherent,  depressed,  and  very  disfiguring.  The  low  grade  of 
inflammation  of  chronic  adenitis  forms  a  good  soil  in  which  the 
tubercular  bacilli  may  grow.  Certain  observers  claim  and  ad- 
duce strong  testimony  to  prove  that  when  enlarged  glands  in 
children  persist  and  finally  pulmonary  tuberculosis  occurs,  the 
infection  is  conveyed  from  the  glands  to  the  lungs,  the  pul- 
monary trouble  being  secondary  to  that  of  the  glands.  Seventy 
or  eighty  per  cent,  of  enlarged  cervical  glands  may  be  said  to 
be  tuberculous.  The  cervical  and  mesenteric  glands  are  most 
frequently  affected  in  children,  but  in  acute  conditions,  such  as 
the  infectious  fevers,  they  become  more  widely  engorged. 

Diagnosis. — Chronic  adenitis  invariably  arises  from  some 
definite  point  of  entrance,  some  lesion,  such  as  chronic  skin 
troubles,  tonsillitis,  ulcers,  etc.,  one  or  two  glands  only  being 
affected.  In  tubercular  adenitis  usually  the  entire  lymphatic 
system  is  more  or  less  affected.  From  syphilitic  adenitis  the 
simple  forms  can  be  differentiated  by  the  history  of  a  primary 
sore,  etc.,  rarely  seen,  however,  in  childhood. 

In  lymphadenoma  the  tumor  is  larger  and  does  not  suppurate. 
In  lymphosarcoma  there  is  longer  duration  and  a  much  larger 
size  of  tumor  before  it  breaks  down.  Polyadenitis  in  children  is 
said  to  be  a  diagnostic  sign  of  tuberculosis  ;  Hodgkin's  disease 
(lymphatic  anemia)  must  be  differentiated  by  the  characteristic 
symptoms,  anemia,  dyspnea,  etc.  ;  also  the  tuberculin  test  is 
clearly  indicated  and  will  almost  certainly  make  the  diagnosis 
clear. 

Prognosis. — Chronic  adenitis  may  end  in  resolution  or  in  sup- 
puration. The  pus  may  burrow  around  large  vessels,  and  so 
weaken  their  walls  as  to  produce  fatal  hemorrhage.  If  the  gland 
should  be  tuberculous,  there  is  always  danger  of  general  in- 
fection. 

Treatment. — The  constitutional  treatment  of  chronic  adenitis 
is  most  important,  good  food,  hygiene,  and  plenty  of  fresh  air 
being  prime  factors  in  the  restoration.  As  to  drugs,  we  rely 
principally  on  reconstructive  agencies,  iron,  arsenic,  oils,  and 
nucleo-albumins.  When  possible,  a  change  of  climate  should 
be  prescribed,  especially  in  tuberculous  cases.  The  good  results 
obtained  in  tuberculous  cases  from  high  altitude  and  dry  climate, 
like  that  of  Colorado,  is  at  times  marvelous,  and  when  possible, 
it  should  be  taken  advantage  of,  while  sea-bathing  is  very  bene- 
ficial and  should  be  recommended  in  such  cases. 


822  CONDITIONS    REQUIRING    SURGICAL    PROCEDURES. 

Local  Treatment. — Resolvents  are  indicated,  such  as  an  oint- 
ment of  iodin  and  iodid  of  potash,  or  an  ointment  of  ichthyol  or 
ichthyol  and  mercury,  gently  rubbed  in  at  night.  The  inter- 
glandular  injection  of  two  minims  of  a  10  per  cent,  solution  of 
chlorid  of  zinc  once  a  week,  or  three  minims  of  equal  parts  of 
carbolic  acid  and  glycerin,  is  said  to  excite  the  growth  of  a  new 
fibrous  tissue  which  encapsulates  the  diseased  portion.  In 
twenty-three  cases  reported  by  Lennelongue,  in  which  he  used 
the  chlorid  of  zinc  solution,  fibrous  encapsulation  occurred  in 
every  case.  Extirpation  of  the  gland  is  strongly  recommended 
by  some  of  the  best  surgeons,  but  we  must  never  lose  sight  of 
the  fact  that  in  removing  the  entire  mass  of  glands  of  one  region 
we  remove  the  valuable  sentinels,  or  guards,  but  so  long  as  these 
canals  are  severed  they  can  no  longer  act  as  avenues  of  invasion 
to  bacteria.  It  would,  therefore,  be  better  to  leave  total  extirpation 
as  a  last  resort.  If  the  gland  should  suppurate,  incision,  curetting, 
and  packing  with  iodoform  gauze  are  indicated.  To  sum  up  the 
treatment :  first,  through  constitutional  and  local  remedies,  backed 
by  climatic  environment.  If  possible,  endeavor  to  secure  resolu- 
tion, leaving  total  extirpation  as  a  last  resort ;  if,  however,  the 
glands  involved  should  be  few  and  there  is  a  strong  suspicion  of 
their  being  tubercular,  it  is  best  to  remove  them  at  once.  Should 
the  glands  suppurate,  proceed  to  incision,  curetting,  and  packing. 


INJURIES  AND  SHOCK. 

Children  bear  injury  badly,  and  in  them  shock  is  most  marked. 
A  slight  loss  of  blood  in  a  child  frequently  causes  serious  pros- 
tration, but  the  recovery  is  equally  prompt  and  complete. 

A  description  of  the  most  serious  injuries  will  be  found  in 
works  upon  general  surgery  and  upon  the  special  surgery  of 
childhood,  and  it  is  therefore  unnecessary  to  attempt  to  give  a  list 
or  an  account  of  them  here. 

Burns. — Burns  from  fire,  acids,  lime,  and  other  corrosive 
agencies,  as  well  as  scalds  from  hot  water,  tea,  soup,  or,  indeed, 
whatever  cause,  are  best  treated  at  first  by  a  normal  salt  solu- 
tion, sterile,  or  a  strong  solution  of  bicarbonate  of  soda.  For 
soothing  qualities  the  application  of  the  oleaginous  preparations 
are  not  particularly  clean,  but  most  comforting,  such  as  boric 
ointment,  carron  oil,  etc.  This  may  be  put  on  over  the  injured 
part,  which  is  then  enveloped  in  sterile  absorbent  cotton  and 
placed  at  rest.  If  the  destruction  is  more  than  superficial,  ulcers 
will  form,  which  must  be  treated  upon  general  antiseptic  prin- 


HARELIP.  823 

ciples.  Here  the  bichlorid  solution  can  not  be  safely  used,  at 
least  not  constantly. 

Children  bear  all  forms  of  chemic  antiseptics  badly,  and  these 
frequently  retard,  if  not  entirely  prevent,  wounds  from  healing. 
Dry  powders  of  a  simple  character,  such  as  bismuth,  oxid  of 
zinc,  and,  if  the  area  upon  which  treatment  is  to  be  directed 
is  not  large,  iodoform,  are  better  than  many  of  the  stronger 
germicides. 

In  the  healing  of  burns  and  scalds  cicatricial"  contractions  of 
the  skin  and  deeper  tissues  are  to  be  expected  unless  great  care 
is  exercised  in  keeping  the  limbs  extended.  Simple  splints  or 
weights  and  pulleys,  if  the  contraction  is  of  the  lower  extremi- 
ties, will  often  prevent  a  very  considerable  amount  of  deformity. 
If,  however,  these  simple  measures  are  not  efficient  after  thorough 
and  persistent  trial,  skin-grafting,  after  the  contracting  bands  are 
divided,  should  be  used  to  close  the  wounds. 

Shock. — The  treatment  of  shock  is  to  put  the  child  at  once  to 
bed  ;  surround  it  with  hot-water  bottles  or  hot-water  bags,  but 
be  certain  that  they  are  protected  so  as  not  to  burn  the  skin  ; 
give  rectal  injection  of  one  or  two  ounces  of  black  coffee  and 
hot  salt  solution  of  a  strength  of  one  dram  to  the  pint,  and  small 
doses  of  strychnin  hypodermically.  If  no  attempt  at  reaction 
follows  this  and  the  injuries  are  not  of  such  a  character  as  to 
prohibit  the  child's  being  moved,  a  hot  bath  is  of  very  great 
service.  Drugs  and  stimulants  given  by  the  mouth,  unless  there 
is  some  effort  at  reaction,  are  of  very  little  service,  because  with 
children,  even  more  than  with  adults,  the  shock  absolutely 
arrests  digestion  and  absorption  from  the  stomach,  and  there  is 
danger  of  filling  the  stomach  with  stimulants  which,  when  reac- 
tion does  set  in,  will  become  suddenly  absorbed  and  cause  the 
patient  to  be  overwhelmed  by  their  accumulated  action. 


HARELIP.— CLEFT  PALATE. 

Harelip  may  be  single  or  double.  It  may  involve  simply  the 
lip  or  be  associated  with  cleft  palate.  Both  are  due  to  faulty 
development  of  the  fetus. 

Children  marked  with  this  deformity  are  usually  unable  to 
nurse  from  the  breast,  as  the  power  of  suction  is  lost,  and  re- 
quire the  greatest  care  in  their  management.  The  harelip  must 
be  operated  upon  early, — a  few  weeks  after  birth,  if  possible, — 
leaving  to  a  later  age — from  three  to  six  weeks — attempts  to 
close  the  cleft  palate. 


824  CONDITIONS    REQUIRING    SURGICAL    PROCEDURES. 

The  closure  of  the  cleft  palate  is  best  done  at  two  sittings,  if 
the  cleft  is  extensive.  The  first  operation  should  be  upon  the 
hard  palate  ;  in  a  few  months  the  cleft  in  the  soft  palate  should 
be  repaired. 

It  may  be  necessary  to  resort  to  the  forced  feeding  of  the  child 
by  means  of  a  soft-rubber  catheter  and  syringe.  A  specially 
constructed  nipple  with  a  shield  to  fit  over  the  cleft  in  the  palate 
sometimes  answers  in  very  young  infants.  These  children  are 
always  of  low  vitality  and,  in  spite  of  all  efforts,  may  die  very 
early. 

DISEASES  OF  THE  JOINTS. 

Diseases  of  the  joints  are  acute  and  chronic.  The  acute  in- 
flammations, synovitis  and  arthritis,  are  produced,  first,  by  injury  ; 
second,  by  rheumatism  ;  third,  they  occur  in  acute  infectious  pro- 
cesses, as  in  the  case  of  scarlet  fever  and  measles. 

The  acute  arthritis  of  infants  which  we  see  occasionally  after 
the  eruptive  fevers  is  an  acute  septic  process,  with  very  rapid 
destruction  of  the  joint  and  the  surrounding  tissues.  The  cor- 
rect diagnosis  of  the  character  of  the  lesion  is  imperative,  and 
if  suppuration  occurs,  active  surgical  interference  is  needed  to 
drain  the  joint  and  prevent  further  destructive  changes. 

Inflamed  conditions  of  the  joint  following  injuries  are  treated 
on  general  surgical  principles  :  by  absolute  rest  and  splint,  with 
hot  or  cold  applications,  the  time-honored  remedy,  lead-water 
and  laudanum,  being  of  comparatively  little  value. 

In  acute  stages  ichthyol  and  lanolin,  12.5  to  25  per  cent., 
rubbed  into  the  joint  after  the  heat  is  applied,  is  frequently  of  great 
benefit.  The  most  essential  point,  however,  is  rest.  If  the  joint 
is  very  much  distended,  either  by  blood  or  articular  fluid,  it  may 
be  well  to  aspirate,  but  only  under  the  very  strictest  antiseptic 
precautions.  The  products  of  inflammation  in  the  joint  must  be 
removed,  or  they  will  lead  to  the  formation  of  adhesions  and 
frequently  destroy  the  usefulness  of  the  joint. 

By  far  the  most  common  cause  of  joint  disease  in  children, 
and,  indeed,  of  diseases  of  the  bone  as  well,  is  tuberculosis. 
The  ankle,  knee,  hip,  spine,  in  fact  any  or  all  of  the  articulations 
of  the  body,  may  be  infected. 

Tubercular  diseases  of  the  joints  should  be  treated  by  con- 
servative methods.  Absolute  rest  in  plaster-of-Paris  and  some 
form  of  splint  apparatus,  and  injections  of  iodoform  and  glycerin 
may  be  tried.  The  method  of  passive  hyperemia,  as  used  in 
Germany,  and  which  consists  in  constriction  both  above  and 
below  the  joint  with  rubber  bands,  the  restriction  being  only  suf- 


DISEASES    OF    THE   JOINTS.  825 

ficient  to  cause  venous  engorgement  without  completely  cutting 
off  the  venous  circulation,  may  be  cautiously  tried.  This  will  re- 
quire care  and  watchfulness  and  a  long  interval  of  time,  but  the 
results,  in  many  instances,  are  undoubtedly  beneficial.  When, 
however,  the  destructive  process  has  advanced  to  such  an  extent 
that  the  joint  is  totally  destroyed,  and  when  the  tubercular  infec- 
tion is  very  profound  and  the  pain  acute  and  persistent,  so  that  the 
child's  bodily  health  is  rapidly  failing,  arthrectomy,  or  excision 
of  the  joint,  should  be  done. 

Bear  in  mind  that  arthrectomy,  or  excision,  will  only  give,  at 
best,  a  mutilated  limb,  but  it  will  often  be  demanded  as  a  life- 
saving  measure  on  account  of  the  rapid  progress  of  the  disease. 

Complications  are  abscesses,  which  are  not  true  abscesses. from 
a  bacteriologic  standpoint ;  they  are  formed  by  the  breaking- 
down  of  tubercular  deposits,  and  are  called  abscesses,  though 
they  do  not  contain  the  germs  of  suppuration  ;  they  are  made  up 
of  cheesy  masses  of  broken-down  tissue  which  are  loaded  with 
tubercle  bacilli.  When  such  abscesses  form,  if  after  a  reason- 
able time  absorption  has  not  occurred,  they  should  be  freely 
opened,  so  that  the  whole  interior  may  be  evacuated.  The  gran- 
ulation tissue,  which  will  be  found  covered  with  tubercular  de- 
posits, should  be  curetted,  first  with  a  sharp  spoon  and  then  with 
a  dull  spoon,  or  gauze  and  sponges  may  be  used.  All  the  time 
a  constant  flow  of  distilled  water  should  be  employed  to  wash 
out  the  wound,  every  particle  of  the  material  being  scraped  away. 
The  wound  is  then  to  be  closed,  without  drainage,  after  a  small 
amount  of  iodoform  has  been  dusted  into  it.  This  method  of 
treatment,  however,  is  only  of  use  when  the  greatest  care  has 
been  exercised  to  perfect  the  antiseptic  technic,  for  if  this  is  not 
the  case,  the  wound  may  become  infected  by  pyogenic  bacteria — 
a  double  infection  will  be  present,  and  much  more  serious  results 
ensue  than  if  the  abscess  were  allowed  to  break  of  itself. 

Many  surgeons  of  wide  experience  in  this  class  of  cases  totally 
oppose  any  surgical  interference  whatever,  claiming  that  in  a  vast 
majority  of  cases  the  ultimate  result  will  be  better  if  the  opening 
occurs  spontaneously  and  the  discharge  of  the  diseased  tissues 
is  left  to  nature  than  if  the  abscess  be  artificially  emptied,  and 
that  the  danger  of  mixed  infection  is  very  greatly  reduced  ;  also 
the  resulting  scar  is  smaller  when  the  abscess  is  allowed  to  open 
spontaneously.  This  is  totally  opposed  to  the  authors'  own 
personal  experience,  but  it  is  the  view  held  by  a  very  large 
number  of  orthopedic  surgeons. 

White  swelling,  or  tubercular  arthritis  of  the  knee,  is  one  of 
the  most  common  diseases  of  the  joints  in  children.  Next,  hip- 


826  CONDITIONS    REQUIRING    SURGICAL    PROCEDURES. 

joint  disease,  ankle-joint  disease,  and  Pott's  disease  of  the 
spine,  or  spondylitis,  occur  most  frequently.  In  all  these  cases 
the  most  important  element  of  treatment  is  absolute  rest  of  the 
joint,  at  first  by  confinement  to  bed  and  the  bed-frame  ;  next, 
by  good  food  and  good  hygienic  surroundings,  fresh  air,  bright 
sunlight,  and,  lastly,  by  a  perfectly  fitting  splint  or  brace. 


INFECTIOUS  OSTEITIS  (OSTEOMYELITIS). 

This  is  an  acute  inflammatory  process  of  the  bone,  due  to  in- 
fection by  staphylococcus  and  streptococcus,  which  find  entrance 
into  the  tissue  either  through  a  wound  in  the  soft  parts  connect- 
ing with  the  bone  or  by  absorption  through  the  general  circula- 
tion, and  are  deposited  at  some  point  where  the  vitality  of  the 
tissues  is  impaired,  either  by  traumatism  or  disease.  It  frequently 
follows  the  eruptive  fevers.  The  epiphyses  of  the  long  bones, 
and  especially  of  the  femur  and  tibia,  are  the  most  frequent  seats 
of  the  disease,  which  soon  extends  to  the  shafts  of  the  bone. 
It  is  so  destructive  in  its  consequences  that  the  whole  of  the  bone 
may  be  destroyed.  It  is,  therefore,  necessary  that  an  early  diag- 
nosis and  prompt  method  of  treatment  be  instituted.  , 

The  symptoms  are  those  of  intense  septicemia,  with  high  tem- 
perature, pain  in  the  limb,  swelling,  and  an  acute  abscess,  which 
rapidly  burrows. 

The  treatment  consists  in  freely  opening  the  tissues  down  to 
the  bone,  trephining  and  chiseling  the  bone  itself,  and  eliminating 
from  the  cavity  the  product  of  the  infective  disease.  Many  cases 
of  so-called  infective  rheumatism  in  children  are  really  those  of 
osteomyelitis.  The  condition  goes  on  for  months  and  months  ; 
the  destruction  of  the  bone  is  very  extensive  ;  abscesses  form 
and  break  spontaneously,  and  after  a  time  the  whole  of  the  bone 
will  be  destroyed.  If,  however,  in  the  early  stages  the  disease 
is  recognized  and  promptly  treated  by  a  surgeon,  many  months 
of  suffering  will  be  saved  and  the  limb  be  preserved,  with  only  a 
moderate  amount  of  deformity. 

OPHTHALMIA  IN  THE  NEW-BORN. 

By  this  term  is  usually  meant  a  form  of  conjunctivitis  occurring 
in  new-born  infants,  produced  in  the  majority  of  cases  by  infection 
from  the  vaginal  secretion  of  the  mother,  who  has  previously 
been  infected  with  gonorrhea.  In  mild  or  moderately  severe 
cases  the  disease  is  limited  to  the  eyelids,  the  conjunctiva,  or  the 
subconjunctival  tissues,  but  when  the  infection  is  severe,  there 


OPHTHALMIA    IN    THE    NEW-BORN.  82/ 

may  be  ulceration  of  the  cornea  or  even  perforation  of  the  eye- 
ball. 

Causes. — Mild  cases  of  inflammation  and  swelling  of  the  eyes 
may  be  produced  by  continued  pressure  during  birth,  or  from  the 
eyes  of  the  child  coming  in  contact  with  a  vaginal  discharge  if  the 
mother  suffers  from  a  simple  catarrhal  vaginitis.  Even  a  healthy 
lochial  discharge  may  produce  a  slight  inflammation.  True  oph- 
thalmia is,  however,  in  almost  all  instances  produced  by  the  eyes 
of  the  child  coming  in  direct  contact,  during  labor,  with  a  vaginal 
discharge  which  is  either  infected  with  the  gonococcus  or  with 
ordinary  pyogenic  germs. 

Uncleanliness  on  the  part  of  the  nurse — as,  for  instance,  in 
the  dressing  and  care  of  an  infant  after  attending  the  mother 
who  has  been  infected — may  be  a  cause. 

Symptoms. — The  disease  usually  begins  about  the  third  day 
after  birth,  the  first  symptoms  being  redness  and  swelling  of  the 
lids,  the  conjunctiva,  and  the  subconjunctival  tissues,  and  is  im- 
mediately followed  by  a  very  free  purulent  discharge.  The  dis- 
charge is  yellowish  or  greenish  in  color  and  may  be  blood- 
streaked  ;  sometimes,  indeed,  there  may  be  distinct  hemorrhages. 
In  a  short  period  of  time  ulceration  of  the  cornea,  followed  by 
sloughing,  takes  place,  and  unless  the  disease  yields  to  treat- 
ment, a  perforation  into  the  anterior  chamber  of  the  eye  follows. 
When  gonorrheal  poisoning  has  been  the  cause,  loss  of  vision 
very  often  results  unless  the  case  is  seen  early  and  very  energetic 
and  careful  treatment  is  instituted.  Neglected  cases  may  end 
not  only  in  loss  of  sight,  but  in  systemic  poisoning  by  pyemia. 

Treatment. — The  prophylaxis  of  ophthalmia  in  the  new-born 
consists  in  first  giving  every  woman  affected  with  any  form  of 
purulent  vaginitis  or  endometritis  an  antiseptic  douche  during  the 
first  stage  of  labor.  The  vagina  should  be  thoroughly  flushed 
with  a  i  :  2OOO  or  even  I  :  1000  solution  of  bichlorid  of  mercury, 
or  a  hot  solution  of  creolin  and  tincture  of  green  soap,  equal 
parts,  in  the  strength  of  one  dram  to  the  quart.  This  should  be 
given  through  a  speculum,  care  being  taken  that  all  the  folds  of 
the  vagina  be  stretched  and  the  whole  birth  canal  thoroughly 
swabbed  by  means  of  wads  of  cotton  held  in  a  pair  of  uterine 
dressing  forceps.  The  next  step  in  the  preventive  treatment 
consists  in  dropping  into  the  infant's  eyes,  immediately  after 
birth,  a  I  per  cent,  solution  of  nitrate  of  silver,  which  should  be 
followed  by  a  drop  or  two  of  salt  solution  in  order  to  neutralize 
any  excess  of  the  nitrate  of  silver.  In  some  cases  a  thorough 
cleansing  of  the  eye  with  a  saturated  solution  of  boric  acid  does 
well.  When  the  eye  has  become  infected,  the  treatment  must 


828  CONDITIONS    REQUIRING    SURGICAL    PROCEDURES. 

be  prompt  and  each  step  accurately  carried  out.  The  strictest 
antiseptic  precautions  must  be  used  to  prevent  the  infection  from 
spreading  to  the  other  eye  where  only  one  is  affected,  and  also 
to  keep  the  disease  from  attacking  those  who  attend  the  patient, 
or,  in  hospitals,  from  spreading  to  other  inmates.  All  cases  of 
ophthalmia  neonatorum  should  be  isolated,  and  a  special  nurse 
be  set  apart  to  attend  such  patients. 

The  treatment  consists  first  in  cleansing  the  eye  every  twenty 
or  thirty  minutes,  night  and  day.  This  should  be  done  by 
instilling  into  the  conjunctival  sac  solutions  of  boric  acid,  by 
means  of  the  ordinary  grooved  eye-dropper  or  a  dropper  with  a 
bulbous  tip.  Care  should  be  taken  that  the  fluid  is  introduced 
well  into  both  angles  of  the  eye,  and  without  force,  taking  care 
to  empty  the  region  thoroughly  of  pus.  In  order  to  reduce  the 
inflammation  there  should  be  constantly  applied  to  the  eye 
small  pieces  of  lint  or  absorbent  cotton, — compresses,  in  fact, — 
which  have  been  rendered  cold  by  letting  them  lie  on  a  cake  of 
ice.  These  should  be  applied  every  minute,  at  least,  and  this 
treatment  should  be  continued  as  long  as  any  discharge  con- 
tinues, taking  care  that  these  are  not  used  should  the  cornea  in 
any  way  become  involved  (haziness,  ulceration,  etc.).  Such  cases 
are  then  much  better  treated  by  the  substitution  of  heat  until  the 
cornea  returns  to  its  proper  condition,  when  cold  may  again  be 
used.  It  has  been  recommended  that  a  few  drops  of  a  I  per 
cent,  solution  of  nitrate  of  silver  should  be  instilled  into  the  eye. 
In  all  cases  the  pupils  should  be  dilated  with  atropin.  It  is  of 
the  utmost  importance  that  all  dressings,  etc.,  coming  from  the 
patient  should  be  burned  as  soon  as  removed,  and  the  nurse 
must  take  the  greatest  possible  care  in  washing  her  hands  both 
before  and  after  attending  the  case. 


INDEX. 


A. 

ABDOMEN,  shape  of,  in  children,  28 
Abdominal  massage  in  chronic  constipa- 
tion, 226 
respiration  in  infants  and  children, 

26 
Abscess,  acute  hepatic,  physical  signs  of, 

271 

ischiorectal,  241 
multiple  hepatic,  272 
of  brain,  589 
retropharyngeal,  431 
Acetonuria,  288 

Acute  articular  rheumatism,  355 
bronchitis,  452 
bronchopneumonia,  463 
congestion  of  kidney,  301 
degeneration  of  kidney,  302 
diffuse  nephritis,  305 
enteritis,  193 
exudative  nephritis,  303 
fatty  degeneration  in  new-born,  73 
hemoglobinuria  of  new-born,  72 
lymphadenitis,  818 
milk  infection,  200 

causes  of,  200 
diagnosis  of,  203 
diet  in,  204 
hot  bath  in,  204 
ice-cap  in,  205 
irrigations  in,  204 
pathology  of,  2OI 
prognosis  of,  203 
prophylactic  treatment  of, 

203 

symptoms  of,  202 
treatment  of  attack  of,  204 
rheumatism,  355 
rhinitis,  426 
yellow  atrophy  of  liver,  280 

pathology  of,  280 
treatment  of,  281 
Adenitis,  chronic,  820 

diagnosis  of,  821 
etiology  of,  820 
pathology  of,  820 
prognosis  of,  821 
symptoms  of,  820 


829 


Adenitis,  chronic,  treatment  of,  821 

local,  822 

in  scarlet  fever,  668 
Adenoid  vegetation,  430 
Adenoma  of  kidney,  318 
Adherent  prepuce,  319 
Adhesive  strips,  rubber,  in  umbilical  her- 
nia, 87 
After-treatment  of  asphyxia  neonatorum, 

53 
of  intubation  of  larynx  in  diphtheria. 

663 

Agenesis,  cortical,  581 
Albuminous  liver,  279 
Albuminuria,  cyclic,  300 
in  diphtheria,  638 
in  scarlet  fever,  673  , 

physiologic,  300 
Alcoholic  neuritis,  562 
Alternating  insanity,  538 
Amblyopia  in  hysteria,  550 
Amphophiles,  333 
Amygdalitis,  433 

Amyloid  degeneration  of  intestines,  218 
disease  of  liver,  279 

diagnosis  of,  280 
pathology  of,  279 
prognosis  of,  280 
symptoms  of,  279 
treatment  of,  280 
Amyotrophies,  602 
Anatomic  changes  in  chlorosis,  336 
Anatomy  of  heart,  391 
Anemia,  335 

lymphatic,  349 
progressive  pernicious,  345 

blood  changes  in,  346 
causes  of,  345 
diagnosis  of,  348 
morbid  anatomy  of,  345 
prognosis  of,  348 
symptoms  of,  347 
treatment  of,  348 
secondary,  350 

diagnosis  of,  352 

from  inherited  syphilis,  353 

from  rickets,  353 

from  tubercular  diseases,  352 


830 


INDEX. 


Anemia,  secondary,  prognosis  of,  352 
symptoms  of,  351 
treatment  of,  352 
simple  primary,  339 
splenic,  340 
Anemias,  primary,  335 
Anesthesia,  forms  of,  in  hysteria,  550 
Aneurysm,  cardiac,  410 
Anhydremia,  330 
Ankle-joint  disease,  826 
Anomalous  epilepsy,  517 
Antepartum  asphyxia,  45 
Anterior  fontanel,  36 
closure  of,  36 
size  of,  36 
Antimony,  effect  of,  on  mother's  milk, 

118 
Antitoxin,  diphtheria,  action  of,  649 

in  limiting  duration  of  the 

disease,  653 
administration  of,  649 
clinical  manifestations  of,  652 
curative  dose  of,  651 
dosage  of,  649 

rules  for,  652 

effects   of,  on    laryngeal    diph- 
theria, 653 
on  pulse   and   circulation, 

652 

on  temperature,  652 
on  the  membrane,  653 
immunizing  dose  of,  651 
influence   of,  on  mortality  rec- 
ords, 653 

technic  of  applying,  648 
unit  of,  648 
Anuria,  285 

causes  of,  285 
hot  fomentations  in,  286 
prognosis  of,  286 
treatment  of,  286 
Anus,  fissure  of,  240 

symptoms  of,  240 
treatment  of,  241 
prolapse  of,  239 
causes  of,  239 
cold  applications  in,  240 
Paquelin's  cautery  in,  240 
symptoms  of,  239 
treatment  of,  239 
Aorta,  stenosis  of,  396 
Aortic  disease,  double,  physical  signs  of, 

416 

insufficiency,  415 
leaflets,  disease  of,  415 
regurgitation,  physical  signs  of,  415 
Aphtha.%  Bednar's,  158 
Aphthous  stomatitis,  157 
causes  of,  157 
treatment  of,  157 


Aphthous  vulvitis  in  children,  743 
Apoplexy  in  new-born,  60 
causes  of,  60 
definition  of,  60 
pathology  of,  60 
symptoms  of,  6 1 
treatment  of,  62 

Apparent  death  of  new-born,  45 
Appearance  of  infant  at  full  term,  19 
Appendicitis,  244 

bacteriology  of,  245 
"  calculous,"  245 
chronic,  250 
diagnosis  of,  248 
etiology  of,  244 
hot  applications  in,  250 

enema  in,  250 
ice-bag  in,  250 
McBurney's  point  in,  247 
morbid  anatomy  of,  246 
operative  treatment  of,  251. 
pain  in,  247 
pathology  of,  244 
salines  in,  250 
symptoms  of,  247 
temperature  in,  247 
the  blood  as  a  guide  in  the  diagno- 
sis of,  353 
treatment  of,  250 
Appendix  vermiformis,  34 
Ann-to-arm  vaccine  inoculation,  686 
Arsenic,  effect  of,  on  mother's  milk,  Il8 

in  eczema,  use  of,  755 
Arterial  trunks,  transpositions  of,  397 
Arthritis,  824 

tubercular,  825 
Ascaris  lumbricoides,  256 
diagnosis  of,  258 
symptoms  of,  257 
treatment  of,  258 
Asphyxia,  antepartum,  45 
neonatorum,  45 

after-treatment  of,  53 

antepartum,  45 

causes  of,  45 

curative  treatment  of,  48 

extra-uterine  causes  of,  45 

hot  bath  in,  49 

Laborde'  s  method  of  treating,  50 

mouth-to-mouth  insufflation  in, 

52 

pathology  of,  46 
postpartum  causes  of,  45 
prognosis  of,  47 
prophylactic  treatment  of,  47 
Ribmont  apparatus  for,  53 
Schul  tze'  s  method  of  treati ng, 50 
stimulants  in,  53 
Sylvester's  method  of  treating, 

50 


INDEX. 


Asphyxia,  neonatorum,  symptoms  of,  46 
synonyms  of,  45 
treatment  of,  47 
rubra  seu  apoplectica,  60 
Asphyxia  des  nouveau  nes,  45 
Aspiration  in  empyema,  494 
Ass's  milk,  105 
Asthma,  bronchial,  458 

diagnosis  of,  460 
pathology  of,  459 
prognosis  of,  460 
symptoms  of,  459 
treatment  of,  460 
following  bronchitis,  treatment  of, 

458 

rachitic,  448 
spasmodic,  458 
Ataxia,  hereditary,  601 

diagnosis  of,  602 
Romberg's  symptom  in,  6oi 
symptoms  of,  601 
treatment  of,  602 
Atelectasis,  acquired,  491 

in  acute  bronchopneumonia,  466 
Athetosis,  517,  519 
Athrepsia,  379 
Atresia  of  intestine,  192 

of  pulmonary  artery,  396 
Atrophic  rhinitis,  428 
Atrophies,  progressive  muscular,  602 
Atrophy,  infantile,  379 

of  liver,  acute  yellow,  280 
simple,  379 

causes  of,  380 
diagnosis  of,  382 
diet  in,  383 
pathology  of,  381 
prognosis  of,  383 
symptoms  of,  381 
treatment  of,  383 
Attenuants,  simple,  151 
Aura  in  epilepsy,  523,  524 
Auricle,  eczema  of,  783 

treament  of,  783 
Auriculoventricular  valves,  anomalies  of, 

396 

Auscultation  in  pericarditis,  405 
Auscultatory   percussion   in  examination 

of  heart,  392 

Automatic  movements,  517 
induced,  517 
treatment  of,  521 
rhythmic  movements,  517,  519 
Autumnal  fever,  619 

B. 

HABINSKI'S  sign,  503 
Bacillus  lanceolatus,  472 

of  Eberth  in  typhoid  fever,  619 


Bacillus  of  Nicolaier  in  tetanus,  567 

of  tuberculosis,  606 
Backhaus'  Kindermilch,  142 
Bacteriology  of  milk,  1 10 
Balanitis,  321 

treatment  of,  321 
Baner's    rules   for  home  modification  of 

milk,  139 
Barley  jelly,  144 
Barley-water,  151 
Barlow's  disease,  375 
Hasedow's  disease,  555 
Basilar  meningitis,  575 
Basophiles,  333 
Bassini's   operation  for  inguinal  hernia, 

236 
Bath,  first,  of  new-born,  89 

hot,  in  acute  milk  infection,  204 
in  infantile  convulsions,  509 
the,  in  infancy,  90 
Baths,  cool,  in  measles,  734 

hot,  in  acute  diffuse  nephritis,  307 
in  chronic  gastritis,  182 
in  croupous  pneumonia,  476,  477 
in  typhoid  fever,  630 
warm,  in  multiple  neuritis,  5°4 
in  tetanus  in  new-born,  77 
Bednar's  aphthae,  158 
Beef  broth,  145 
Beef-juice,  145 
Belladonna,  effect  of,  on  mother's  milk, 

118 
Birth,  changes  in  circulation  of  blood  at, 

22 

Black  measles,  731 
smallpox,  682 

Bladder,  inflammation  of,  298 
position  of,  30 
shape  of,  30 
stone  in,  295 

causes  of,  295 
diagnosis  of,  297 
symptoms  of,  296 
treatment  of,  298 
Blennorrhagia  of  navel,  76 
Blisters  in  ulcer  of  stomach  in  children, 

189 

Blood  as  a  guide  in  diagnosis  of  appen- 
dicitis, 353 
changes  in  chlorosis,  336 

in  circulation  of,  at  birth,  22 
in   progressive  pernicious  ane- 
mia, 346 
diseases  of,  327 
fetal  circulation  of,  21 
general  considerations  on,  327 

pathologic  changes  in,  330 
in  Hodgkin's  disease,  349 
in  leukocythemia,  342 
in  pneumonia,  353 


832 


INDEX. 


Blood,  instruments  used  in  inspection  of, 

334 

of  infants,  334 

Sharpless'  table  on  condition  of  the, 
in  differentiation  of  diseases,  354 
staining,  329 
Blood-corpuscles,  327 

nucleated,  332 
Body,  ringworm  of,  777 
Body-lice,  769 
Boil,  763 

"blind,"  763 
Bones,  Wormian,  37 
Bothriocephalus  latus,  259 
Brain,  38 

abscess  of,  589 
weight  of,  at  birth,  39 
Brain-tumors,  585 
Brand  bath  in  typhoid  fever,  630 
Breast,  94 

feeding  from  the,  94 

contraindications  to,  97 
Breasts,  the,  in  infancy,  41 
Bright' s  disease,  acute,  305 
causes  of,  305 
complications  of,  307 
hot  baths  in,  307 
pathology  of,  305 
prognosis  of,  307 
sequelae  of,  307 
symptoms  of,  306 
treatment  of,  307 
urine  in,  306 

Broadbent'  s  sign  of  pericarditis,  404 
Bromids,  eruption  from,  745 
Bronchial  asthma,  458 
Bronchitis,  acute,  452 
causes  of,  4.52 
counterirritants  in,  456 
diagnosis  of,  455 
pathology  of,  452 
prognosis  of,  454 
symptoms  of,  453 
treatment  of,  455 
asthma  in,  458 
chronic,  457 

diagnosis  of,  457 
complications  of,  457 
treatment  of,  458 
emphysema  in,  458 
fibrinous,  458 
pharyngeal  catarrh  in,  458 
Bronchopneumonia,  acute,  463 
atelectasis  in,  466 
causes  of,  463 
complications  of,  467 
diagnosis  of,  468 
pathology  of,  464 
prognosis  in,  468 
sequelae  of,  467 


Bronchopneumonia,  acute,  symptoms  of, 

466 

treatment  of,  469 
chronic,  469 

pathology  of,  469 
prognosis  of,  471 
symptoms  of,  470 
treatment  of,  471 
tuberculous,  acute,  610 

caseation  in,  610 
morbid  anatomy  of,  610 
symptoms  of,  6il 
Broth,  beef,  145 
chicken,  146 
mutton,   145 

Bruit  de  diable  in  chlorosis,  338 
Bubonic  plague,  738 
Buhl's  disease,  73 
Burns,  822 

C. 

CACHEXIA,  periosteal,  375 
Calculi,  renal,  316 
"Calculous"  appendicitis,  245 
Calomel     fumigations     in     membranous 

croup,  447 

in  cyclic  vomiting,  184 
Cancrum  oris,  161 
Capacity  of  lUngs  in  infants  and  children, 

25 

of  stomach  at  birth,  31 
Caput  succedaneum,  63 

aspiration  in,  64 

causes  of,  63 

definition  of,  63 

incision  in,  64 

pathology  of,  63 

situation  of,  63 

synonyms  of,  63 

treatment  of,  63 

varieties  of,  63 
Carcinoma  of  kidney,  318 
Cardiac  aneurysm,  410 

disease,  chronic,  physical    signs  of, 

417 
diseases,  391 

classification  of,  394 
functional,  398 
organic,  400 
Carpopedal  spasm,  449 

spasms,  506 
Cataleptic  insanity,  539 
Catarrh,  acute  gastric,  174 

renal,  301 

chronic  gastro-intestinal,  218 
intestinal,  chronic,  195 
desquamative,  218 
pharyngeal,  treatment  of,  458 
Catarrhal  croup,  440 


INDEX. 


833 


Catarrhal  enteritis,  acute,  193 
chronic,  195 

fever,  epidemic,  700 

laryngitis,  440 
acute,  440 

proctitis,  241 

stomatitis,  simple,  156 
causes  of,  156 
symptoms  of,  156 
treatment  of,   156 
Catalonia,   539 

Cautery,  actual,  in  rectal  prolapse,  238 
Cecum,  position  of,  in  children,  33 
Cephalhematoma,  64 

causes  of,  64 

definition  of,  64 

diagnosis  of,  66 

pathology  of,  65 

prognosis  of,  67 

spurious,  63 

subaponeurotic,  63 

symptoms  of,  65 

synonyms  of,  64 

treatment  of,  67 
Cerebral  diminution  of  reflex  action,  503 

excess  of  reflex  action,  502 

hemorrhage,  60 

meningitis,  simple,  570 

palsies,  infantile,  578 
Cerebrospinal  meningitis,  epidemic,   706 

sclerosis,  599 
Certified  milk,  123 
Ceruminosis,  784 

treatment  of,  784 
Chemistry  of  milk,  108 
Chicken  broth,  146 
Chicken-pox.     See  Varicella,  687 
Child,  posture  and  general  expression  of, 

in  health  and  disease,  42 
Childhood  and  youth,  hysteria  in,  546 

hysteria  of,  517,  518 

jaundice  occurring  during,  267 
Children,  abdomen  in,  shape  of,  28 

bath  in,  90 

diaphragm  in,  position  of,  27 

diet  of,  from  second  year,  147 

from  sixth  to  eighteenth  month, 

143 
disease  in,  general  symptomatology 

and  diagnosis  of,  41 
diseases  of,  nervous  manifestations 

in,  495 

exercise  in,  91 
feeble,  foods  for,  793 

hygiene  of,  792 

modified  rest  treatment  of,  794 
feeding  and  foods  in,  94 
general  hygiene  of,  88 
genital  organs  in,  care  of,  92 
heart  in,  position  of,  23 

53 


Children,  increase  of  weight  in,  17 

insanity    and    disturbances    of    the 
mind  in,  537 

and  mental  disorders  of,  treat- 
ment of,  542 
lung  capacity  in,  25 
lungs  in,  position  of,  25 
pancreas  in,  position  of,  29 
pulse-rate  in,  25 
respiration  in,  rate  of,  26 

type  of,  26 

spleen  in,  position  of,  28 
table  of  increase  in  weight  of,  18 
thorax  in,  size  of,  27 
thymus  gland  in,  physiology  of,  27 
ulcer  of  stomach  in,  185 
Chills  and  fever,  689 
Chloral  hydrate,  eruption  from,  746 
Chloremia,  335 

Chloretone   in  ulcer  of  stomach  in  chil- 
dren, 189 
Chlorosis,  335 

anatomic  changes  in,  336 
blood  changes  in,  336 
causes  of,  336 
climatic  change  in,  339 
complications  in,  338 
diagnosis  of,  338 
"  humming-top  "  murmur  in,  338 
pathology  of,  336 
prognosis  of,  339 
symptoms  of,  337 
treatment  of,  339 
Cholera  infantum,  200 

causes  of,  200 

diagnosis  of,  203 

diet  in,  204 

hot  bath  in,  204 

ice-cap  in,  205 

pathology  of,  201 

prognosis  of,  203 

prophylactic  treatment  of,  203 

symptoms  of,  202 

treatment  of  attack  of,  204 
Chorea,  528 

causes  of,  529 
diagnosis  of,  531 
habit,  535 
hot  bath  in,  535 
Huntingdon's,  537 
intention,  528 
minor,  528 
passive,  528 
pathology  of,  531 
postparalytic,  531,  537 
Sydenham's,  528 
symptoms  of,  530 
treatment  of,  532 

nutritional  repair  in,  532 

preventive,  532 


834 


INDEX. 


Chorea,  treatment  of,  reeducation  of  co- 
ordination in,  532 
rest  in,  532 

specific  medication  in,  532 
Choreic  insanity,  539 
Chronic  adenitis,  820 

appendicitis,  250 

bronchitis,  457 

bronchopneumonia,  469 

congestion  of  kidney,  301 

croup  of  intestines,  218 

cystitis,  299 

enteritis,  195 

gastritis,  178 

nephritis,  309 

rheumatism,  363 

rhinitis,  427 

Chvostek's  sign  in  tetany,  514 
Circular  insanity,  538 
Circulation,  changes  in,  at  birth,  22 

in  fetus,  21 
Cirrhosis  of  liver,  274 
Class-Gradwohl    diplococcus   of    scarlet 

fever,  666 

Clavus  hystericus,  548 
Cleft  palate,  823 

Climate  in  chronic  pulmonary  tuberculo- 
sis, 617 

Clothing  in  croupous  pneumonia,  478 
Cocain  in  ulcer  of  stomach  in  children, 

189 
Cold  applications  in  croupous  pneumonia, 

477 

in  enuresis,  295 
in  pericarditis,  406 
in  prolapse  of  anus,  240 
in  rheumatic  fever,  360 
bath  in  typhoid  fever,  630 
Cold-water  injections  in  rectal  prolapse, 

238 

Colic  in  lead  paralysis,  567 
intestinal,  227 

causes  of,  227 
diagnosis  of,  228 
diet  in,  229 
enema  in,  229 
hot  applications  in,  229 
symptoms  of,  228 
treatment  of,  229 

Colostrum,  human,  composition  of,  106 
Concept  reflexes,  501 
Condensed  milk,  152 
Congenital  diseases  of  heart,  395 

'hernia,  235 
Congestion  of  kidney,  acute,  301 

chronic,  301 
of  liver,  270 
Constipation,  chronic,  224 

abdominal  massage  in,  226 
causes  of,  224 


Constipation,  chronic,  diet  in,  226 
electricity  in,  226 
enema  in,  225 
symptoms  of,  225 
treatment  of,  225 
Constitutional  diseases,  355 
Contracted  kidney,  309 
Contraindications  to  breast  feeding,  97 
Convulsions,  504 

in  brain-tumor,  586 
in  lead  paralysis,  567 
infantile,  505 

causes  of,  506 

table  of,  511 
emetics  in,  510 
hot  bath  in,  509 
leeches  in,  510 
oxygen  in,  510 
prognosis  of,  508 
symptoms  of,  505 
treatment  of,  509 
Convulsive  tic,  536 
Coordinated  tics,  complex,  536 
Cor  biloculare,  396 
bovinum,  416 
triloculare,  396 
villosum,  401 
Corpuscles,  blood-,  327 

nucleated,  332       j*~ 
Corrigan  pulse,  415 
Cortical  agenesis,  581 
Coryza,  426 
Cough,  450 

constant,  451 
dry,  451 
moist,  451 
paroxysmal,  451 
Counterirritants  in  croupous  pneumonia, 

479 

Counterirritation  in  infantile  cerebral  pal- 
sies, 584 

Cow,  care  of  the,  1 20 
Cowpox,  685 
Cow's  milk,  106 

percentage   composition   of,   at 
different   stages   of  milking, 

112 

Crab-lice,  769 
Craniotabes  in  rachitis,  367 
Cream,  116 

Creams,  evaporated,  153 
Creasote  in  chronic  pulmonary  tubercu- 
losis, 616 
Croup,  440 

catarrhal,  440 

causes  of,  441 
diagnosis  of,  442 
symptoms  of,  441 
treatment  of,  443 
false,  440 


INDEX. 


835 


Croup,  membranous,  445 

calomel  fumigations  in,  447 

diagnosis  of,  447 

prognosis  of,  447 

serum  treatment  of,  447 

symptoms  of,  445 

treatment  of,  447 
spasmodic,  440 

Mitchell's  treatment  of,  444 

treatment  of,  443 
true,  445 

Croupous  pneumonia,  471 
rhinitis,  429 
stomatitis,  163 

symptoms  of,  163 

treatment  of,  164 
Cyclic  albuminuria,  300 
vomiting,  183 

causes  of,  183 

diagnosis  of,  184 

diet  in,  184 

treatment  of,  184 
Cystitis,  298 

causes  of,  298 
chronic,  299 

symptoms  of,  299 

treatment  of,  299 
diet  in,  299 
irrigation  in,  299 
prognosis  of,  299 
symptoms  of,  298 
treatment  of,  299 

D. 

DEATH,  apparent,  of  new-born,  45 
Decomposition  of  milk,  no 
Deficiency  in  secretion  of  milk,  98 
Deformities  in  rachitis,  368 
Degeneration  of  intestines,  amyloid,  218 

of  kidney,  acute,  302 
Delusional  insanity,  primary,  539 
Dentition,  normal  and  delayed,  168 
Dermatitis,  743 

calorica,  744 

medicamentosa,  745 

traumatica,  743 

venenata,  744 
Desquamative  catarrh,  intestinal,  218 

nephritis,  acute,  303 
Development  of  lungs,  799 

of  mind,  809 

of  muscles,  804 

of  nervous  system,  807 

of  sense  organs,  795 

of  skin,  797 

of  teeth,  physiology  of,  168 
Diabetes  mellitus,  385 
causes  of,  385 
diagnosis  of,  386 


Diabetes  mellitus,  Fehling's  test  in,  386 
fermentation  test  in,  387 
phenyl-hydrazin     test    in, 

387 

hygienic  treatment  of,  387 
medicinal  treatment  of,  388 
morbid  anatomy  of,  385 
prognosis  in,  387 
symptoms  of,  386 
treatment  of,  387 
Diacetic  acid  in  urine,  288 
Diaphragm,    position    of,    in    children, 

27 

Diarrhea,  chronic  irritative,  195 
dysenteric,  211 
infectious,  206 
mechanical,  193 
simple,  193 
summer,  206 

Diet  and  hygiene  of  lactation,  97 
in  acute  diffuse  nephritis,  308 
enteritis,  194 
gastritis,  178 
milk  infection,  204 
in  chronic  constipation,  226 
enteritis,  197,  198 
gastritis,  181 
nephritis,   313 
in  cirrhosis  of  liver,  276 
in  congestion  of  liver,  271 
in  croupous  pneumonia,  478 
in  cyclic  vomiting,  184 
in  cystitis,  299 
in  ileocolitis,  215 
in  intestinal  colic,  229 
in  jaundice  of  childhood,  268 
in  marasmus,  383 
in  mucous  disease,  221,  222 
in  rachitis,  373 
in  rheumatic  fever,  362 
in  scarlet  fever,  678 
in  scorbutus,  379 
in    subacute     milk    infection,    209, 

210 

in  typhoid  fever,  628 
in   ulcer   of    stomach    in    children, 

189 

of  children  from  second  year,  147 
from  the  sixth  to  the  eighteenth 

month,  143 

Diffuse  nephritis,  acute,  305 
Digestion  in  infants,  32 
Digestive  organs,  diseases  of,  155 
Dilatation  of  stomach,  191 
Diphtheria,  632 

albuminuria  in,  638 
antitoxin  in,  action  of,  649 

in  limiting  duration  of  the 

disease,  653 
administration  of,  649 


836 


INDEX. 


Diphtheria,  antitoxin  in,  curative  dose  of, 

651 

dosage  of,  649 
rules  for,  652 

effects  of,   on   laryngeal   form, 

653 

on  membrane,  653 
on  pulse  and  circulation^  2 
on  temperature,  652 

immunizing  dose  of,  651 

influence      of,      on      mortality 
records,  653 

technic  of  applying,  648 

unit  of,  648 
bacillus  of,  632 
causes  of,  632 
complications  of,  655 
constitutional  treatment  of,  645 
diagnosis  of,  639 
disinfection  in,  647 
duration  of,  638 
dyspnea  in,  638 
extubation  in,  665 
incubation  period  of,  636 
intubation  in,  658 

advantages  of,  664 

after-treatment  of,  663 

dangers  of,  662 

disadvantages  of,  664 

indications  for,  664 

method  of  introducing  tube  in, 
660 

prolonged  use  of  tube  in,  665 

removal  of  tube  in,  665 
laryngeal,  445 

intubation  in,  658 
local  applications  in,  642 
membrane  in,  636 
mode  of  transmission  of,  634 
paralyses  in,  638 
pathology  of,  635 
prodromes  of,  636 
prognosis-in,  640 
prophylaxis  of,  641 

isolation  in,  641 
pulse  in,  638 
sequelae  of,  655 
sick-room  in  care  of,  641 
symptoms  of,  636 
toluol  solution  in,  643 
tracheotomy  in,  656 

after-treatment  of,  658 

incision  in,  657 

indications  for,  656 
treatment  of,  641 
varieties  of,  634 
Diphtheric  paralysis,  565 
proctitis,  242 
stomatitis,  163 

symptoms  of,  163 


Diplococcus  pneumoniae,  472 
Discharges,  intestinal,  in  infancy,  34 

"  rice-water,"  35 
Disease,  Barlow's,  375 

Basedow's,  555 

Bright' s,  acute,  305 

Buhl's,  73 

Friedreich's,  601 

Graves',  555 

Hodgkin's,  349 

in  children,  general  symptomatology 
and  diagnosis  of,  41 

mucous,  218 

Raynaud's,  557 

Winckel's,  72 
Diseases  characterized  by  jaundice,  70 

constitutional,  355 

in    the    new-born   characterized   by 
hemorrhage,  59 

of  blood,  327 

of  digestive  organs,  155 

of  ear,  781 

of  endocardium,  410 

of  esophagus,  173 

of  genital  organs,  319 

of  genito-urinary  system,  284 

of  heart,  391 

of  intestines,  192 

of  joints,  824 

of  kidney,  301 

of  liver,  264 

of  mouth,  156 

of  nervous  system,  495 

of  pericardium,  403 

of  peritoneum,  244 

of  rectum,  237 

of  respiratory  organs,  422 

of  skin,  743 

of  stomach,  174 

of  tongue,  165 

produced  by  septic  infection,  74 

Sharpless'  table  on  condition  of  blood 
in  differentiation  of,  354 

specific  infectious,  605 
Disinfection  in  diphtheria,  647 
Disorders  of  speech,  437 
Disseminated  sclerosis,  599 
Disturbances  of  lactation,  loo 
Diverticulum,  Meckel's,  85 

tumor,  85 

Drugs,  effect  of,  on  mother's  milk,  118 
Dry  cough,  451 
Duchenne's  paralysis,  81 
Ductus  arteriosus,  22 

persistence  of,  396 
Dysenteric  diarrhea,  211 
Dysentery,  211 
Dyspepsia,  acute,  174 
Dyspnea  in  diphtheria,  638 
Dystrophy,  602 


INDEX. 


837 


E. 

EAR  complications  in  scarlet  fever,  675 
diseases  of,  781 
external,  diseases  of,  783 
foreign  bodies  in,  785 
furuncles  of,  783 

foreign  bodies  in,  treatment  of,  785 

internal,  diseases  of,  791 

prognosis  of,  791 

symptoms  of,  791 

treatment  of,  791 

middle,  acute  inflammation  of,  785 

symptoms  of,  786 
suppurative     inflammation 

of,  787 

treatment  of,  787 
chronic  catarrhal  inflammation 

of,  790 
causes  of,  790 
pathology  of,  790 
treatment  of,  790 
suppurative     inflammation 

of,  788 

causes  of,  788 
symptoms  of,  788 
treatment  of,  789 
diseases  of,  785 

Ecchymoma  cephalaematome,  64 
Eclampsia  nutans,  5X7>  52° 

rotans,  517*  52° 
Ecthyma,  746 

treatment  of,  747 
Eczema,  747 
acute,  752 

Lassar's  paste  in,  753 
ointments  in,  753 
treatment  of,  752 
cause  of,  748 
chronic,  754 

arsenic  in,  755 
of  scalp,  754 
treatment  of,  754 
differential  diagnosis  of,  75^ 
eruption  in,  748 
erythematosum,  756 

diagnosis   of,    from    erysipelas, 

756 

from  syphiloderma  erythe- 
matosum, 759 
hygiene  in,  749 
local  applications  in,  75° 
of  auricle,  783 

treatment  of,  783 
papulopustulosum,  diagnosis  of,  from 

scabies,  759 
papulosum,  756 

diagnosis  of,  from  lichen,  758 
from  syphiloderma    papu- 
losum, 759 


Eczema  papulosum,   diagnosis   of,   from 

urticaria,  756 
pustulosum,  diagnosis  of,  from  favus, 

758 

from   syphiloderma   pustu- 
losum, 760 
squamosum,  diagnosis  of,  from  pity- 

riasis  capitis,  757 
from  pityriasis  rubra,  758 
from  psoriasis,  757 
from    syphiloderma    squa- 
mosum, 759 

from  tinea  circinata,  758 
treatment  of,  749 
vesiculosum,  diagnosis  of,from  herpes 

zoster,  757 

Edematous  fibromata,  429 
Electric  reactions  in  infantile  spinal  par- 
alysis, 592 

Electricity  in  acute  lymphadenitis,  819 
in  chronic  constipation,  226 
in  infantile  cerebral  palsies,  584 
in  laryngismus  stridulus,  450 
in  mucous  disease,  224 
in  multiple  neuritis,  565 
in  obstetric  paralysis,  84 
Emetics  in  acute  gastritis,  176 

in  infantile  convulsions,  510 
Emphysema,  pulmonary,  462,  463 

treatment  of,  458 
Empyema,  492 

diagnosis  of,  493 

exploring  needle  in,  493 
prognosis  of,  494 
symptoms  of,  493 
treatment  of,  494 
Encysted  hernia,  235 
Endocardial   changes    in   organic    heart 

disease,  402 
Endocarditis,  410 
causes  of,  410 
clinical  history  of,  411 
compensation  in,  412 
in  rheumatic  fever,  357 
mitral  regurgitation  in,  413 

stenosis  in,  414 
physical  signs  of,  413 
rest  in,  418 
symptoms  of,  412 
treatment  of,  418 
Endocardium,  diseases  of,  410 
Enema,  nutrient,  in  ulcer  of  stomach  in 

children,  189 

Enemata,  hot,  in  appendicitis,  250 
in  acute  enteritis,  194 
in  chronic  constipation,  225 

enteritis,  199 
in  intestinal  colic,  229 
in  proctitis,  243 
Enteric  fever,  619 


838 


INDEX. 


Enteritis,  acute,  193 

causes  of,  193 
diet  in,  194 
enemata  in,  194 
prognosis  of,  194 
symptoms  of,  193 
treatment  of,  194 
catarrhal,  acute,  193 

chronic,  195 
chronic,  195 

causes  of,  195 
diagnosis  of,  196 
diet  in,  197,  198 
enemata  in,  199 
hygiene  in,  197 
medicinal  treatment  of,  199 
prognosis  of,  197 
symptoms  of,  196 
treatment  of,  197 
Enterocolitis,  206 
chronic,  195 
Enuresis,  291 

causes  of,  292 
cold  applications  in,  295 
definition  of,  291 
hygiene  in,  294 
prognosis  of,  294 
treatment  of,  294 
Eosinophile,  327 
Epidemic  catarrhal  fever,  700 

cerebrospinal  meningitis,  706 
influenza,  700 
Epididymitis,  323 

treatment  of,  323 
Epilepsy,  521 

anomalous,  517 
aura  in,  523 
causes  of,  522 
diagnosis  of,  5  25 
focal,  522 
Jacksonian,  524 
masked,  524 
morbid  anatomy  in,  522 
nocturnal,  524 
partial,  524 

preventive  treatment  of,  525 
prognosis  of,  525 
somnaic,  524 
symptoms  of,  522 
treatment  of,  525 
Epileptic  insanity,  539 
Epispadias,  326 
Erb's  paralysis,  8 1 

sign  in  tetany,  514 
Eruption  in  eczema,  748 
in  measles,  730 
in  rubella,  736 
in  scarlet  fever,  669 
in  typhoid  fever,  624 
in  varicella,  688 


Eruption  in  variola,  68 1 
Erythema,  760 

infantile,  761 

intertrigo,  761 

treatment  of,  761 

iris,  762 

multiforme,  762 

treatment  of,  762 

nodosum,  762 

vaccinium,  761 

varieties  of,  760 

variolosum,  762 
Erythrocytes,  329 
Esophagitis,  acute,  173 

treatment  of,  174 
Esophagus,  173 

diseases  of,  173 
Estivo-autumnal  variety  of  malarial  fever, 

691 

Etat  mamellone,  179 
Evaporated  creams,  153 
Examination  of  heart,  392 

of  milk,  113 
Excoriation  of  navel,  76 
Exercise  in  infancy,  91 
Exercises  and  outings,  forms  of,  800 
Exophthalmic  goiter,  555 
Exploratory  needle  in  multiple  hepatic 

abscess,  272 

Exploring  needle  in  empyema,  493 
Expression,  general,  of  child  in  health 

and  disease,  42 

Extension  in  acute  myelitis,  597 
Extubation,  665 
Exudative  nephritis,  acute,  303 
Eyes,  hygiene  of,  after  birth,  88 

F. 

FACIAL  paralysis,  81 

False  croup,  440 

Faradism  in  infantile  paralysis,  594 

Fat  in  milk,  109 

estimation  of,  114 

Feser's  lactoscope  in,  115 
Marchand's  tube  in,  115 
Fatty  degeneration,  acute,  in  new-born, 73 
causes  of,  73 
pathology  of,  73 
symptoms  of,  73 
treatment  of,  73 
liver,  278 
"  Favus  cup,"  77^ 
Fears,  morbid,  540 
Feces,  incontinence  of,  241 
Feeble-mindedness,  540 
Feebleness   in   girls   about   the   age   of 

puberty,  811 

Feeding  and  food  of  infants  and  children, 
94 


INDEX. 


839 


Feeding  by  use  of  modified  milk  of  ani- 
mals, 105 
by  wet-nurse,  104 
from  breast,  94 

of  infants  prematurely  born,  56 
Fehling's     test     in    diabetes    mellitus, 

386 

Femoral  hernia,  237 
Fermentation   test   in  diabetes  mellitus, 

387 
Feser's  lactoscope  in  estimation  of  fat  in 

milk,  115 
Fetal  circulation,  21 

heart,  peculiarities  of,  23 
"  Fettmilch,"  141 
Fever  and  ague,  689 

epidemic  catarrhal,  700 

gastric,  174 

glandular,  741 

intermittent,  689 

malarial,  689 

rheumatic,  355 

scarlet,  666 

typhoid,  619 
Fibrinous  bronchitis,  treatment  of,  458 

macroglossia,  166 
Fibrocystic  tumor  of  kidney,  318 
Fibroma  of  kidney,  318 
Fibromata,  edematous,  429 
Fibrous  tumors  of  nose,  430 
Fissure  of  anus,  240 
Flour-ball,  144 
Focal  epilepsy,  522 

Follicular  inflammation  of  intestinal  mu- 
cous membrane,  chronic,  218 

stomatitis,  157 
Fontanel,  anterior,  36 
closure  of,  36 
size  of,  36 

posterior,  36 

closure  of,  36 

Food  in  croupous  pneumonia,  478 
Foods  containing  starch,  dextrin,  or  mal- 
tose, 149 

for  infants  and  invalids,  151 

Liebig's,  150 

proprietary,  149 

intended    to   be    used   without 

milk,  150 

Foramen  ovale,  patency  of,  395 
Foreign  bodies  in  ear,  785 

treatment  of,  785 
Formulas,  milk,  103,  104 
Friedreich's  disease,  601 
Frost  bite,  744 

treatment  of,  744 

Fulminating  type  of  scarlet  fever,  672 
Functional  disturbances  of  heart,  398 
Funicular  hernia,  235 
Furuncle,  763 


Furuncle  of  external  ear,  783 

treatment  of,  784 
treatment  of,  763 

G. 

GAERTNER'S  "Fettmilch,"  141 
Gangrene  of  lung,  491 
oral,  161 
symmetric,  557 
Gangrenous  stomatitis,  161 

causes  of,  161 

cauterants  in,  163 

pathology  of,  161 

symptoms  of,  161 

treatment  of,  163 
Gastralgia,  190 
causes  of,  190 
counterirritation  in,  190 
definition  of,  190 
treatment  of,  190 
Gastric  catarrh,  acute,  174 

chronic  infantile,  179 
dilatation,  191 

diagnosis  of,  191 

irrigation  in,  192 

pathology  of,  191 

symptoms  of,  191 

treatment  of,  192 
fever,  174 

juice  in  infancy,  composition  of,  32 
ulcer  in  children,  185 
Gastritis,  174 
acute,  174 

causes  of,  174 

diet  in,  178 

emetics  in,  176 

lavage  in,  176 

pathology  of,  1 76 

prognosis  of,  176 

purgatives  in,  176,  177 

rectal  injections  in,  177,  178 

symptoms  of,  175 

treatment  of,  176 
chronic,  178 

baths  in,  182 

causes  of,  179 

diagnosis  of,  181 

diet  in,  181 

hygiene  in,  181 

lavage  in,  183 

massage  in,  182 

pathology  of,  179 

prognosis  of,  181 

symptoms  of,  179 

treatment  of,  181 

varieties  of,  179 
varieties  of,  174 
Gastro-adenitis,  174 
Gastro-enteritis,  chronic,  179 


840 


INDEX. 


Gastrointestinal  catarrh,  chronic,  218 
hemorrhage,  69 
causes  of,  69 

hot-water  injections  in,  70 
pathology  of,  70 
symptoms  of,  70 
treatment  of,  70 

Gavage  in  infants  prematurely  born,  56 
Gelatin-water,  151 
Gelbsucht,  70 

General  considerations  on  physical  devel- 
opment, 792 

hygiene  in  infants  and  children,  88 
septic  infection  of  new-born,  74 
symptomatology   and    diagnosis    of 

disease  in  children,  41 
tuberculosis,  609 
Genital  organs,  care  of,   in  children,  92 

diseases  of,  319 

Genito-urinary  system,  diseases  of,  284 
German  measles,  735 
Gilles  de  la  Tourette's  disease,  536 
Gin-drinker's  liver,  274     . 
Girls,  feebleness  in,   about   the  age   of 

puberty,  811 
Glandular  fever,  741 

gastritis,  chronic,  178 
Glomerulonephritis,  acute,  305 
Glossitis,  167 
Glottis,  spasm  of,  448 
Glycerinized  vaccine  lymph,  686 
Glycosuria,  physiologic,  286 
Goat's  milk,  105 
Goiter,  exophthalmic,  555 
symptoms  of,  555 
tachycardia  in,  555 
treatment  of,  557 
Von  Graefe's  symptom  of,  556 
Gonorrheal  vulvovaginitis,  321 
Grand  mal,  523 
Granular  kidney,  309 
Graves'  disease,  555 
Gray  hepatization  in  pneumonia,  473 
Green  sickness,  335 
Gyrospasm,  517,  520 

H. 

HABIT  chorea,  535 

movements,  535 

Hair,  care  and  treatment  of,  in  acute  in- 
fectious diseases,  741 
"  Hairy  heart,"  401 
Halsted's  operation  for  inguinal  hernia, 

236 

Harelip,  823 
Head,  the,  in  infancy,  36 

measurements  of,  36 
the,  proportionate  size  of,  and  thorax, 
table  of,  38 


Headache  in  brain-tumor,  586 

sick,  559 
Head-lice,  769 

Head-nodding  and  shaking,  517,  519 
Hearing  in  infancy,  40 
Heart,  anatomy  of,  391 

auriculoventricular  valves  of,  anoma- 
lies of,  396 
development  of,  23 
diseases  of,  391 

classification  of,  394 
congenital,  395 

diagnosis  of,  397 
prognosis  of,  397 
symptoms  of,  397 
treatment  of,  397 
general  considerations  of,  391 
organic,  400 

pathology  of,  400 
examination  of,  392 

auscultatory  percussion  in,  392 
phonendoscope  in,  393 
fetal,  23 

foramen  ovale  of,  patency  of,  395 
functional  disturbances  of,  398 
causes  of,  398 
diagnosis  of,  399 
prognosis  of,  400 
treatment  of,  4*00 
gross  anomalies  of,  397 
physiology  of,  391 
position  of  apex-beat  of,  in  children, 

23 

valvular   disease  of,  importance   of 
physical  signs  other  than  murmurs 
in  diagnosis  of,  394 
ventricular   septum   of,    defects    of, 

396 

weight  of,  at  birth,  25 
variations  in,  391 
Heart- beat  in  infants  and  children,  rate 

of,  25 
Hematoma  of  sternocleidomastoid,  67 

symptoms  of,  68 
Hematuria,  289 
causes  of,  289 
diagnosis  of,  291 
hemorrhage  in,  location  of,  290 
treatment  of,  291 
urine  in,  289 

Hemianesthesia  in  hysteria,  550 
Hemichorea,  528 
Hemicrania,  559 
Hemoglobinuria,  291 

acute,  of  new-born,  72 

pathology  of,  72 
symptoms  of,  72,  73 
causes  of,  291 
diagnosis  of,  291 
treatment  of,  291 


INDEX. 


841 


Hemopericardium,  407 
Hemorrhage,  cerebral,  60 
gastrointestinal,  69 
causes  of,  69 
hot-water  injection  in,  70 
pathology  of,  70 
symptoms  of,  70 
treatment  of,  70 
location  of,  in  hematuria,  290 
meningeal,  60 
umbilical,  69 

causes  of,  69 
ligation  in,  69 
prognosis  of,  69 
prophylaxis  in,  69 
treatment  of,  69 

Hemorrhages  from  mucous  surfaces,  62 
causes  of,  62 
treatment  of,  62 
in  new-born,  59 
causes  of,  59 
symptoms  of,  60 
Hemorrhagic  smallpox,  682 
Hemorrhoids,  241 
Hepatic  abscess,  acute  physical  signs  of, 

271 
multiple,  272 

diagnosis  of,  272 

exploratory  needle  in, 

272 

prognosis  in,  272 
treatment  of,  272 
congestion,  270 
Hepatitis,  interstitial,  274 
causes  of,  274 
diagnosis  of,  276 
diet  in,  276 
hygiene  in,  277 
pathology  of,  275 
prognosis  of,  276 
symptoms  of,  275 
treatment  of,  276 
suppurative,  273 
Hereditary  ataxia,  601 

chorea,  537 
Hernia,  235 

congenital,  235 
diagnosis  of,  236 
encysted,  235 
femoral,  237 
funicular,  235 
infantile,  235 

inguinal,  Bassini's  operation  for,  236 
Halsted's  operation  for,  236 
radical  cure  of,  236 
truss  in,  237 
prognoses  of,  236 
symptoms  of,  236 
treatment  of,  236 
umbilical,  86 


Hernia,  umbilical,  rubber  adhesive  strips 

in,  87 
treatment  of,  87 

truss  in,  87 
Herpes  iris,  762 
zoster,  764 

causes  of,  765 

diagnosis  of,  765 

treatment  of,  765 
Hip-joint  disease,  825 
Hives,  779 
Hobnail  liver,  274 
Hodgkin's  disease,  349 

blood  in,  349 

causes  of,  349 

diagnosis  of,  350 

pathologic  anatomy  in,  349 

prognosis  of,  350 

symptoms  of,  349 

treatment  of,  350 
Holt's  method  of  home  modification  of 

milk,  132 

Home  modification  of  milk,  132 
Hot  applications  in  appendicitis,  250 

in  intestinal  colic,  229 
bath  in  acute  milk  infection,  204 

in  asphyxia  neonatorum,  49 

in  chorea,  535 

in   croupous    pneumonia,    476, 

477 

in  infantile  convulsions,  509 
baths  in  acute  diffuse  nephritis,  307 
fomentations  in  anuria,  286 
Hot- water  bag  in  gastralgia,  190 

injections  in  gastro-intestinal  hemor- 
rhage, 70 
"Humming-top"   murmur  in  chlorosis, 

338 

Huntingdon's  chorea,  537 
Hydatid  disease  of  liver,  281 
diagnosis  of,  282 
prognosis  of,  282 
treatment  of,  282 
Hydremia,  330 
Hydrocele,  323 

diagnosis  of,  324 

in  female  children,  324 

symptoms  of,  324 
treatment  of,  324 
Hydrocephalus,  553 

acute,  symptoms  of,  553 
chronic,  symptoms  of,  554 
diagnosis  of,  554 
lumbar  puncture  in,  555 
tapping  of  ventricles  in,  554 
treatment  of,  554 
Hydropericardium,  407 
Hygiene,  diet  and,  of  lactation,  97 

general,  of  infants  and  children,  88 
in  chronic  gastritis,  181 


842 


INDEX. 


Hygiene  in  cirrhosis  of  liver,  277 
in  rachitis,  372 

Hyperaemia  cerebri  traumatica,  60 

Hyperemia,  renal,  301 

Hypertrophic  rhinitis,  chronic,  428 

Hypertrophy  of  tonsils,  437 

Hypospadias,  325 

Hypostatic  pneumonia,  491 

Hysteria  in  childhood,  517,  518 
and  youth,  546 

amblyopia  in,  550 
anesthesias  in,  550 
ischemia  in,  550 
mental  phenomena  in,  547 
opisthotonos  in,  549 
paralysis  in,  55° 
paroxysm  in,  548 
stigmata  in,  550 
symptoms  of,  547 
tachypnea  in,  551 
treatment  of,  55 l 

Hysteric  insanity,  539 

I. 

ICE-BAG  in  appendicitis,  250 
Ice-cap  in  acute  milk  infection,  205 
Ice-poultice  in  croupous  pneumonia,  477 
Ictere,  70 

Icterus  in  new-born,  70 
causes  of,  7 1 
symptoms  of,  71 
synonyms  of,  70 
treatment  of,  71 
Idiocy,  540 
Ileocolitis,  211 

causes  of,  211 

diagnosis  of,  214 

diet  in,  215 

hygiene  in,  215 

intestinal  irrigation  in,  216 

pathology  of,  212 

preventive  treatment  of,  215 

prognosis  of,  214 

symptoms  of,  213 

treatment  of,  215 
Imbecility,  540 

moral,  539 
Impetigo  contagiosa,  766 

treatment  of,  767 
Incontinence  of  feces,  241 

of  urine,  291 
Incubation  period  of  diphtheria,  636 

of  variola,  68 1 

Incubator  for  infants  prematurely  born,  55 
Indicanuria,  287 

causes  of,  287 

test  for,  287 

Stokvis',  287 

treatment  of,  288 


Indigestion,  acute  intestinal,  193 

chronic  intestinal,  195 
Infancy,  bath  in,  90 

care  of  mouth  in,  91 
exercise  in,  91 
hearing  in,  40 
sight  in,  39 
sleep  in,  90 

Infant  and  child,  physiology  of,  17 
appearance  of,  at  full  term,  19 
feeding,  breeds  of  cows  best  adapted 

for,  119 

gastric  juice  in,  32 
size  of,  at  birth,  17 
temperature  of,  at  birth,  21 
variations  in  normal  temperature  in, 

21 

weight  of,  at  birth,  17 
Infantile  atrophy,  379 
cerebral  palsies,  57^ 
convulsions,  505 
erythema,  761 
hernia,  235 
jaundice,  70 
scurvy,  375 
spinal  paralysis,  589 
Infants,  blood  of,  334 

feeding  and  food  in,  94 
general  hygiene  of,  88 
lung  capacity  in,  25 
muscular  exercise  in,  91 
prematurely  born,  feeding  of,  56 
gavage  in,  56 
light  in,  55 
management  of,  54 
nourishment  in,  55 
peptonized  milk  in,  58 
temperature  in,  54 
pulse-rate  in,  25 

quantity  of  urine  secreted  in,  30 
respiration  in,  rate  of,  26 

type  of,  26 
Infection,   septic   diseases  produced  by, 

74  . 
Infectious  diarrhea,  206 

diseases,  acute,  care  and  treatment 

of  the  hair  in,  741 
specific,  605 
osteitis,  826 
Inflammation  of  liver,  suppurative,  273 

syphilitic,  273 
of  middle  ear,  acute,  785 

su-ppurative,  787 
chronic  catarrhal,  790 
suppurative,  788 
Inflammatory  rheumatism,  355 
Inflation  of  bowel  in  intussusception,  234 
Influenza,  epidemic,  7°° 
bacillus  of,  701 
causes  of,  701 


INDEX. 


843 


Influenza,  epidemic,  diagnosis  of,  702 
mixed  infections  in,  701 
prognosis  of,  704 
symptoms  of,  704 
treatment  of,  705 
Inguinal  hernia,  Bassini's  operation  for, 

236 

Halsted's  operation  for,  236 
radical  cure  of,  236 
truss  in,  237 
Injections,  cold-water,  in  rectal  prolapse, 

238 

Injuries  and  shock,  822 
Inorganic  salts  in  milk,  no 
Insanity  and  disturbances  of  the  mind  in 

children,  537 
cataleptic,  539 
choreic,  539 

circular  or  alternating,  538 
delusional,  primary,  539 
epileptic,  539 
hysteric,  539 
moral,  539 
treatment  of,  542 
Inspection  in  liver  diseases,  265 

in  pericarditis,  404 
Inspiration  pneumonia,  45,  77 
Instruments  used  in  inspection  of  blood, 

334 

Insufficiency,  mitral,  414 
Insufflation,  mouth-to-mouth,  in  asphyxia 

neonatorum,  52 
Insular  sclerosis,  599 
Interlobar  pleurisy,  489 
Intermittent  fever,  689 
Internal  ear,  diseases  of,  791 
Interstitial  hepatitis,  274 
causes  of,  274 
diagnosis  of,  276 
diet  in,  276 
hygiene  in,  277 
pathology  of,  275 
prognosis  of,  276 
symptoms  of,  275 
treatment  of,  276 
nephritis,  chronic,  309 
Intestinal  catarrh,  chronic,  195 
colic,  227 

causes  of,  227 
diagnosis  of,  228 
diet  in,  229 
enema  in,  229 
hot  applications  in,  229 
symptoms  of,  228 
treatment  of,  229 
desquamative  catarrh,  218 
discharges  in  infancy,  34 
character  of,  35 
indigestion,  acute,  193 
chronic,  195 


Intestinal    mucous    membrane,     chronic 

follicular  inflammation  of,  218 
obstruction,  230 

by  intussusception,  230 
treatment  of,  233 

by  strangulation,  230 

by  strictures,  230 

causes  of,  231 
exciting,  231 
predisposing,  231 

diagnosis  of,  253 

from  appendicitis,  233 
from  colic,  233 
from  enteritis,  233 
from    impaction    of   feces, 

233 

from  volvulus,  230 
mechanical,  230 
pain  in,  232 
prognosis  of,  233 
symptoms  of,  232 
tympanites  in,  232 
vomiting  in,  232 
parasites,  254-263 
tract,  malformations  of,  192 
treatment  of,  192 
Intestine,  atresia  of,  192 
large,  33 

length  of,  in  infants,  33 
small,  32 

length  of,  in  infants,  32 
stenosis  of,  192 
strangulation  of,  230 
stricture  of,  230 

Intestines,  amyloid  degeneration  of,  218 
croup  of,  chronic,  218 
diseases  of,  192 

Intubation  in  whooping  cough,  718 
of  larynx  in  diphtheria,  658 
advantages  of,  664 
after-treatment  of,  663 
dangers  of,  662 
disadvantages  of,  664 
indications  for,  664 
tube,  method  of  introducing,  660 
prolonged  use  of,  665 
removal  of,  665 
Intussusception,  230 
diagnosis  of,  233 
inflation  of  bowel  in,  234 
nourishment  in,  234 
operation  for,  235 
prognosis  of,  233 
rectal  injections  in,  234 
symptoms  of,  232 
treatment  of,  233 
lodids,  eruption  from,  746 
lodoform,  effect  of,  on  mother's  milk,  118 
Irrigation  in  acute  milk  infection,  204 
in  cystitis,  299 


844 


INDEX. 


Irrigation  in  gastric  dilatation,  192 
in  ileocolitis,  216 
in  subacute  milk  infection,  210 
in  ulcer  of  stomach  in  children,  189 

Ischemia  in  hysteria,  550 

Ischiorectal  abscess,  241 

Ttch,  the,  773 

Ivory  vaccine  points,  686 

Ivy-poisoning,  744 


J- 

JACKSONIAN  epilepsy,  524 
Jaundice,  diseases  characterized  by,  70 
infantile,  70 

malignant,  in  new-born,  71 
diagnosis  of,  72 
symptoms  of,  72 
treatment  of,  72 
occurring  during  childhood,  267 

counterirritation      in, 

268 

diet  in,  268 
massage  in,  268 
treatment  of,  268 
Joints,  diseases  of,  824 
tubercular,  824 


K. 

KIDNEY,  acute  congestion  of,  301 
causes  of,  301 
pathology  of,  301 
prognosis  of,  301 
symptoms  of,  301 
treatment  of,  301 

chronic  congestion  of,  301 
causes  of,  301 
pathology  of,  301 
symptoms  of,  302 
treatment  of,  302 

contracted,  309 

degeneration  of,  acute,  302 
causes  of,  302 
pathology  of,  302 
symptoms  of,  302 
treatment  of,  302 

diseases  of,  301 

granular,  309 

lardaceous,  309 

sclerosis  of,  309 

tuberculosis  of,  317 
symptoms  of,  317 

tumors  of,  318 

pathology  of,  318 
symptoms  of,  318 

waxy,  309 
Kidneys,  29 

in  scorbutus,  377 


Kidneys,  position  of,  29 
Kindermilch,  Backhaus',  142 
Kopfgeschwulst,  63 
Koplik's  spots  in  measles,  730 

L. 

LABORATORIES,  milk,  128 
Laborde's   method   of  artificial   respira- 
tion, 50 

Lacrimal  glands  in  infancy,  40 
Lactation,  diet  and  hygiene  of,  97 

disturbances  of,  IOO 
Lactoscope,  Feser's,  in  estimation  of  fat 

in  milk,  115 

Lactose,  estimation  of,  in  milk,  117 
La  Grippe,  700 
Land  scurvy,  772 
Lardaceous  kidney,  309 

liver,  279 
Large  intestine,  33 

length  of,  in  infants,  33 
Laryngeal  diphtheria,  445 
Laryngismus,  448 
stridulus,  448 

causes  of,  448 
diagnosis  of,  449 
electricity  in,  450 
prognosis  of,  449 
symptoms  of,  448 
treatment  of,  449 
Laryngitis,  catarrhal,  440 

pseudomembranous,  445 
Laryngospasm,  448 

Larynx,  intubation  of,  in  diphtheria,  658 
advantages  of,  664 
after-treatment  of,  663 
dangers  of,  662 
disadvantages  of,  664 
indications  for,  664 
O'Dwyer's  instruments  for, 

660 

Lassar's  paste  in  acute  eczema,  753 
Latent  tetany,  514 

Lavage,  gastric,  in  mucous  disease,  223 
in  acute  gastritis,  176 
in  chronic  gastritis,  183 
in  subacute  milk  infection,  210 
in  ulcer  of  stomach  in  children,  189 
Lead  paralysis,  566 
Leeches  in  infantile  convulsions,  510 
Leptomeningitis,  570 
Leukemia,  340 
Leukocythemia,  340 
blood  in,  342 
causes  of,  340 
diagnosis  of,  344 
lymphatic,  343 
pathologic  anatomy  of,  341 
prognosis  of,  344 


INDEX. 


845 


Leukocythemia,  symptoms  of,  343 

treatment  of,  344 
Leukocytosis,  331 
Lice,  769 

Lichen  tropicus,  767 
Liebig's  foods,  150 
Ligation  in  umbilical  hemorrhage,  69 
Light  in  infants  prematurely  born,  55 
Lime-water,  152 
Lingua  geographica,  167 
Lipemia,  330 

Liver,  acute  yellow  atrophy  of,  280 
albuminous,  279 
amyloid  disease  of,  279 
cirrhosis  of,  274 
causes  of,  274 
diagnosis  of,  276 
diet  in,  276 
hygiene  in,  277 
pathology  of,  275 
symptoms  of,  275 
treatment  of,  276 
congestion  of,  270 
diet  in,  271 
prognosis  of,  271 
purgatives  in,  271 
symptoms  of,  270 
treatment  of,  271 
diseases  of,  264 

inspection  in,  265 
palpation  in,  266 
percussion  in,  266 
fatty,  278 

symptoms  of,  279 
treatment  of,  279 
gin-drinker's,  274 
hobnail,  274 
hydatid  disease  of,  281 
lardaceous,  279 
sclerosis  of,  274 
scrofulous,  279 
suppurative  inflammation  of,  273 

symptoms  of,  273 
syphilitic  inflammation  of,  273 
diagnosis  of,  273 
symptoms  of,  243 
waxy,  279 

Lobar  pneumonia,  471 
Lockjaw,  567 

Lumbar  puncture  in  hydrocephalus,  555 
Lung,  gangrene  of,  491 
Lungs,  capacity  of,  in  infants  and  chil- 
dren, 25 

development  of,  799 
position  of,  in  children,  25 
tuberculosis  of,  610 
Lymphadenitis,  818 
acute,  818 

causes  of,  818 

cold  applications  in,  819 


Lymphadenitis,  acute,  diagnosis  of,  819 
electricity  in,  819 
incision  in,  819 
pathology  of,  818 
prognosis  of,  819 
symptoms  of,  819 
treatment  of,  819 

local,  819 

retropharyngeal,  431 
Lymphangitis,  818 
Lymphatic  anemia,  349 
leukocythemia,  343 
Lymphocyte,  327 

M. 

MACROCYTES,  329 
Macrocythemia,  331 
Macroglossia,  165 
fibrinous,  166 

symptoms  of,  166 
treatment  of,  1 66 
Malarial  fever,  689 

causes  of,  690 
diagnosis  of,  698 
estivo-autumnal  variety  of,  691 
pathologic  anatomy  of,  695 
pathology  of,  692 
prognosis  of,  698 
prophylaxis  of,  698 
symptoms  of,  695 
treatment  of,  698 
types  of,  691 

quartan,  691 
quotidian,  691 
tertian,  691 
variations  of,  691 
parasites,  692 

Mannaberg's  table  of,  696 
Malformations  of  intestinal  tract,  192 
Malignant  jaundice  in  new-born,  Jl 
polyadenitis,  73^ 
purpuric  fever,  706 
Management  of  infants  prematurely  born, 

54 

Mania,  538 

Mannaberg's  table  of  malarial  parasites, 

696 

"  Mappy"  tongue,  167 
Marasmus,  379 

causes  of,  380 

diagnosis  of,  382 

diet  in,  383 

pathology  of,  381 

prognosis  of,  383 

symptoms  of,  381 

treatment  of,  383 
Marchand's  tube  in  estimation  of  fat  in 

milk,  115 
Marsh  fever,  689 


846 


INDEX. 


Masked  epilepsy,  524 
Massage,  abdominal,  in  chronic  constipa- 
tion, 226 

in  acute  myelitis,  598 
in  chronic  gastritis,  182 
in  infantile  cerebral  palsies,  584 

spinal  paralysis,  594 
in  jaundice  of  childhood,  268 
in  mucous  disease,  224 
in  multiple  neuritis,  565 
in  obstetric  paralysis,  84 
"Mast-cell,"  333 
Mastitis  in  new-born,  80 

hot  fomentations  in,  80 
McBurney's  point  in  appendicitis,  247 
McCollom' s  types  of  scarlet  fever,  672 
Measles,  729 
black,  731 
causes  of,  730 
complications  of,  733 
cool  baths  in,  734 
diagnosis  of,  732 
eruption  in,  730 
German,  735 
incubation  period  in,  729 
Koplik's  spots  in,  730 
Muenier's  sign  of,  730 
pathology  of,  732 
prophylaxis  of,  733 
sequelae  of,  732,  733 
sick-room  in,  733 
symptoms  of,  730 
treatment  of,  733 

Measurements  of  head  in  infancy,  36 
Mechanical  diarrhea,  193 
Meckel's  diverticulum,  85 
Meconium,  34 
Megaloblast,  332 
Megalocytes,  329 
Megrim,  559 
Melancholia,  538 
Melanemia,  331 
Melena  in  new-born,  79 
causes  of,  79 
definition  of,  79 
symptoms  of,  79 
treatment  of,  79 
Membranous  croup,  445 
proctitis,  242 
rhinitis,  429 

Meningeal  hemorrhage,  60 
Meningitis,  basilar,  575 
cerebral,  simple,  570 

causes  of,  570 
course  of,  573 
diagnosis  of,  573 
morbid  anatomy  of,  572 
prognosis  of,  573 
symptoms  of,  571 
tache  cerebrale  in,  572 


Meningitis,    cerebral,    simple,  treatment 

of,  574 

cerebrospinal,  epidemic,  706 
causes  of,  707 
diagnosis  of,  709 
pathology  of,  707 
prognosis  of,  709 
symptoms  of,  707 
treatment  of,  709 
plastic,  572 

posterior  basic,  simple,  574 
purulent,  570,  572 
tubercular,  575 
causes  of,  575 
course  of,  577 
diagnosis  of,  577 
pathology  of,  577 
prognosis  of,  577 
symptoms  of,  575 
treatment  of,  577 
Mental  disorders  of  children,  treatment 

of,  542 
Mercurial  stomatitis,  164 

symptoms  of,  165 
treatment  of,  165 

Mercury,  effect  of,  on  mother's  milk,  1 18 
Microblast,  332 
Microcytes,  329 
Microcythemia,  331 
Microglossia,  165 

Microscopic  examination  of  milk,  114 
Micturition,  physiology  of,  292 
Migraine,  559 

causes  of,  559 
pathology  of,  560 
symptoms  of,  559 
treatment  of,  560 
visual  disturbances  in,  560 
Miliaria,  767 
alba,  767 
crystallina,  767 
diagnosis  of,  768 
differential  diagnosis  of,  768 
papulosa,  768 
prognosis  of,  768 
rubra,  767 

et  vesiculosa,  767 
treatment  of,  768 
Milk,  ass's,  105 

bacteriology  of,  I IO 
care  of,  1 21 
certified,  123 
chemistry  of,  108 
condensed,  152 
cow's,  1 06 

percentage  composition  of,  at 
different  stages  of  milking, 
112 

cream  in,  116 
decomposition  of,  no 


INDEX. 


847 


Milk,  deficiency  in  secretion  of,  98 

examination  of,  113 
microscopic,  114 

fat  in,  109 

estimation  of,  1 14 

Feser's  lactoscope  in,  115 
Marchand's  tube  in,  115 

formulas,  103,  104 

Rotch's,  for  infants  prematurely 
born,  58 

goat's,  105 

home  modification  of,  132 

Baner's  rules  for,  139 
Holt's  method  of,  132 
Rotch's  method  of,  134 
use  of  the  Materna  in,  141 
Westcott's  method  of,  137 

human,  percentage  of  solids  in,  113 

infection,  acute,  200 

causes  of,  200 
diagnosis  of,  203 
diet  in,  204 
hot  bath  in,  204 
ice-cap  in,  205 
irrigations  in,  204 
pathology  of,  201 
prognosis  of,  203 
prophylactic   treatment  of, 

203 

symptoms  of,  202 
treatment  of  attack,  204 
subacute,  206 

causes  of,  207 
diagnosis  of,  209 
diet  in,  209,  210 
hygiene  in,  2IO 
irrigations  in,  210 
lavage  in,  2IO 
pathology  of,  208 
prognosis  of,  209 
symptoms  of,  208 
tonics  in,  211 
treatment  of,  209 

inorganic  salts  in,  no 

laboratories,  128 

lactose  in,  estimation  of,  117 

modified,  126 

of  animals,  feeding  by  use  of, 

105 

mother's,  effect  of  drugs  on,  118 

Pasteurization  of,  125 

peptonized,  in   infants   prematurely 

born,  58 

predigestion  of,  142 
proteids  in,  109 

estimation  of,  118  , 

reaction  of,  1 10 
salts  of,  estimation  of,  117 
sterilization  of,  123 
sugar  in,  109 


Milk,  supervision  of  production    of,  by 

boards  of  health,  121 
Milk-teeth,  168,  169 
Millet,  159 

Mind,  development  of,  809 
Mitchell's  treatment  of  croup,  444 
Mitral  insufficiency,  413 
obstruction,  414 
regurgitation,  413 

physical  signs  of,  413 
stenosis,  414 

physical  signs  of,  414 
Modification  of  reflexes,  502 
Modified  milk,  126 
Moral  imbecility,  539 

insanity,  539 
Morbid  fears,  540 
Morbilli,  729 

Morphin,  effect  of,  on  mother's  milk,  118 
in  infantile  convulsions,  510 
in  ulcer  of  stomach  in  children,  189 
Morrow's     differential     points    between 
syphilis   and   scrofulous    skin-lesions, 
722 

Motor  excitements,  504 
Mouth,  155 

aphthous  sore,  157 
care  of  the,  in  infancy,  91 
diseases  of  the,  156 
Movements,  automatic,  517 
induced,  5 1 7 
rhythmic,  517,  519 
habit,  535 
Mucous  disease,  218 

causes  of,  218 
diagnosis  of,  220 
diet  in,  221,  222 
electricity  in,  224 
gastric  lavage  in,  223 
hygiene  in,  221 
massage  in,  224 
pathology  of,  219 
prognosis  of,  221 
salines  in,  223 
symptoms  of,  219 
tonics  in,  224 
treatment  of,  221 
polypi  of  nose,  429 
surfaces,  hemorrhages  from,  62 
Muenier's  sign  of  measles,  730 
Muguet,  159 
Multiple  hepatic  abscess,  272 

neuritis,  561 
Mumps,  711 

causes  of,  "Jli 
complications  in,  711 
diagnosis  of,  711 
prognosis  of,  712 
symptoms  of,  711 
treatment  of,  J12 


848 


INDEX. 


Muscle  reflexes,  501 
Muscles,  development  of,  804 
Muscular  atrophies,  progressive,  602 
pains  in  lead  paralysis,  567 
paralysis,  pseudohypertrophic,  603 
rheumatism,  362 
sense,  504 
Mutton  broth,  145 
Myelitis,  acute,  594 

causes  of,  594 
course  of,  595 
extension  in,  597 
massage  in,  598 
pathology  of,  597 
prognosis  of,  597 
symptoms  of,  595 
treatment  of,  597 
Myelocytes,  333 
Myocarditis,  401,  408 

acute  suppurative,  410 
causes  of,  409 
diagnosis  of,  410 
pathology  of,  409 
sequelae  of,  410 
symptoms  of,  409 
treatment  of,  410 
Myocardium,  affections  of,  407 
causes  of,  407 
symptoms  of,  407 
Myopathies,  602 
Myxedema,  558 
cause  of,  558 
symptoms  of,  558 

N. 

NASAL  fibrous  tumors,  430 
Navel,  excoriation  of,  76 
inflammation  of,  "j6 
Nephritis,  chronic.  309 
causes  of,  309 
diagnosis  of,  312 
diet  in,  313 
hot  baths  in,  313 
pathology  of,  309 
prognosis  of,  312 
symptoms  of,  310 
treatment  of,  313 
desquamative,  acute,  303 
diffuse,  acute,  305 

causes  of,  305 
complications  in,  307 
diet  in,  308 
hot  baths  in,  307 
pathology  of,  305 
prognosis  in,  307 
sequelae  in,  307 
symptoms  of,  306 
treatment  of,  307 
urine  in,  306 


Nephritis,  diffuse,  acute,  venesection  in, 

308 

chronic,  without  exudation,  309 
exudative,  acute,  303 
causes  of,  303 
pathology  of,  303 
prognosis  of,  305 
symptoms  of,  304 
interstitial,  chronic,  309 
parenchymatous,  acute,  303 

chronic,  309 

septic  interstitial,  acute,  303 
tubular,  acute,  303 
Nervous    manifestations    in    diseases  of 

children,  495 
system,  development  of,  807 

diseases  of,  495 
Nettle-rash,  779 
Neuritis,  561 

alcoholic,  562 
multiple,  561 

causes  of,  561 
diagnosis  of,  564 
electricity  in,  565 
massage  in,  565 
morbid  anatomy  of,  562 
symptoms  of,  562 
treatment  of,  564 
warm  baths  in,  564 
wrist-drop  in,  563 
optic,  in  brain-tumor,  586 
Neuron,  the,  499 
Neutrophile,  329 
New-born,  acute  fatty  degeneration  in, 

73 

cause  of,  73 
pathology  of,  73 
symptoms  of,  73 
treatment  of,  73 
hemoglobinuria  of,  72 
apoplexy  in,  60 
causes  of,  60 
definition  of.  60 
pathology  of,  60 
symptoms  of,  61 
treatment  of,  62 
apparent  death  of,  45 
diseases  in,  characterized  by  hemor- 
rhage, 59 

eyes  in,  care  of,  88 
first  bath  of,  89 
general  septic  infection  of,  74 

preventive     treatment 

of,  75 

symptoms  of,  74 
treatment  of,  75 
hemorrhages  in,  59 
causes  of,  59 
symptoms  of,  60 
icterus  of,  70 


INDEX. 


849 


New-born,  icterus  of,  causes  of,  71 
symptoms  of,  7 1 
synonyms  of,  70 
treatment  of,  71 
malignant  jaundice  in,  fl 
diagnosis  of,  72 
symptoms  of,  72 
treatment  of,  72 
mastitis  in,  80 
melena  in,  79 
ophthalmia  in,  826 
tetanus  in,  76 
cause  of,  76 
symptoms  of,  77 
warm  baths  in,  77 
Night-terrors,  538 
"  Nine-day  fits,"  76 
Nocturnal  epilepsy,  524 
Noma,  161 
Normal  dentition,  168 
Normoblast,  332 
Nourishment  in  infants  prematurely  born, 

55 

Nucleated  corpuscles,  332 
Nursery,  the,  92 
Nutrient  enema  in  ulcer  of  stomach  in 

children,  189 

O. 

OAT  jelly,  144 
Oatmeal -water,  151 
Obstetric  paralysis,  8 1 

causes  of,  81 

curative  treatment  of,  84 

definition  of,  81 

diagnosis  of,  83 

electricity  in,  84 

massage  in,  84 

prognosis  of,  83 

prophylactic  treatment  of,  84 

symptoms  of,  82 

treatment  of,  84 
Obstruction,  intestinal,  230 

mitral,  414 

Ocular  neuritis  in  lead  paralysis,  567 
O'Dwyer's  instruments  for  intubation  of 

larynx  in  diphtheria,  660 
Oidium  albicans  in  parasitic  stomatitis, 

159 

Oligemia,  330 
Oligochromemia,   330 
Oligocythemia,  330 
Omphalitis,  76 

causes  of.  76 

treatment  of,  76 
Omphalomesenteric  duct,  persistence  of, 

85 
Operation  for  intussusception,  235 

in  rectal  prolapse,  238 
54 


Operative  treatment  of  appendicitis,  251 
Ophthalmia  in  new-born,  826 

causes  of,  827 

prophylaxis  of,  827 

symptoms  of,  827 

treatment  of,  827 
Opisthotonos  in  hysteria,  549 
Opium,  effect  of,  on  mother's  milk,  118 

eruption  from,  746 
Optic  neuritis  in  brain-tumor,  586 
Oral  gangrene,  161 
Orchitis,  322 

in  mumps,  711 
treatment  of,  322 
Osteitis,  infectious,  826 
Osteomyelitis,  826 
Otitis  media  acuta,  785 

chronic  catarrhal,  790 
suppurative,  788 

suppurative,  787 

treatment  of,  787 

Outings,  exercises  and,  forms  of,  800 
Ovarian  tumors  in  children,  325 
Oxygen  in  infantile  convulsions,  510 
Oxyuris  vermicularis,  254 

mode  of  infection  by,  255 

treatment  of,  255 
Ozena,  428 

P. 

PACK,  cold,  in  croupous  pneumonia,  477 
hot,  in  acute  diffuse  nephritis,  307, 

308 
Pain  in  appendicitis,  247 

in  intestinal  obstruction,  232 
Palate,  cleft,  823 
Palpation  in  liver  diseases,  266 

in  pericarditis,  404 
Palsies,  cerebral,  infantile,  578 
causes  of,  579 
counterirritation  in,  584 
description  of,  579 
differential     diagnosis    of, 

583 

diplegic,  578,  580 
effects  of,  summary  of,  582 
electricity  in,  584 
hemiplegic,  578,  579 
massage  in,  584 
monoplegic,  578,  580 
morbid  anatomy  of,  581 
paraplegic,  578,  580 
pathology  of,  581 
prognosis  of,  583 
spastic,  578 
symptoms  of,  579 
treatment  of,  583 
Pancreas,  29 

situation  of,  29 


850 


INDEX. 


Panotitis,  791 

prognosis  of,  791 

Paquelin  cautery  in  prolapse  of  anus,  240 
Paracentesis  in  pericarditis,  407 
Paralyses  in  lead  paralysis,  566 
Paralysis,  diphtheric,  565 
prognosis  of,  565 
treatment  of,  566 
Duchenne's,  8 1 
Erb's,  81 
facial,  8l 
in  hysteria,  55° 
infantile  spinal,  589 

causes  of,  589 
diagnosis  of,  590 

from    acute     cerebral 

palsy,  591 

from  meningitis,  590 
from    peripheral  neu- 
ritis, 591 

electric  reactions  in,  592 
faradism  in,  594 
massage  in,  594 
pathology  of,  590 
prognosis  of,  593 
reflexes  in,  593 
symptoms  of,  591 
treatment  of,  594 
lead,  566 

diagnosis  of,  566 

colic   and   muscular  pains 

in,  567 

convulsions  in,  567 
ocular  neuritis  in,  567 
paralyses  in,  566 
treatment  of,  567 

muscular,  pseudohypertrophic,  603 
diagnosis  of,  604 
pathology  of,  603 
prognosis  of,  604 
symptoms  of,  603 
treatment  of,  604 
obstetric,  81 

causes  of,  81 
curative  treatment  of,  84 
diagnosis  of,  83 
electricity  in,  84 
massage  in,  84 
prognosis  of,  83 
prophylactic  treatment  of,  84 
symptoms  of,  82 
treatment  of,  84 

of  central  origin  following  labor,  82 
Paranoia,  539 
Paraphimosis,  320 

treatment  of,  320 
Parasites,  intestinal,  254-263 
Parasitic  stomatitis,  159 
causes  of,  159 
curative  treatment  of,  160 


Parasitic   stomatitis,  o'idium  albicans   as 

cause  of,  159 

prophylactic  treatment  of,  1 60 
symptoms  of,  160 
treatment  of,  160 
Parenchymatous  nephritis,  acute,  303 

chronic,  309 
Paretic  dementia,  540 
Parotitis,  specific,  711 
Paroxysm  in  hysteria,  548 
Partial  epilepsy,  524 
Pasteurization  of  milk,  125 
Patency  of  foramen  ovale,  395 
Pediculosis,  769 

treatment  of,  769 
Peliosis  rheumatica,  772 
Peptonized  milk  in  infants   prematurely 

born,  58 
Percussion  in  liver  diseases,  266 

in  pericarditis,  405 
Pericarditis,  401,  403 

auscultation  in,  405 

Broadbent's  sign  of,  404 

cold  applications  in,  406 

diagnosis  of,  405 

etiology  of,  403 

hot  applications  in,  406 

in  rheumatic  fever,  357 

inspection  in,  404 

palpation  in,  404 

paracentesis  in,  407 

percussion  in,  405 

physical  signs  of,  404 

plastic,  401 

prognosis  of,  406 

symptoms  of,  403 

treatment  of,  406 
Pericardium,  diseases  of,  403 
Perinephritis,  314 

causes  of,  314 

diagnosis  of,  315 

from  inflammation  of  hip  joint, 

315 

from  psoas  abscess,  315 
pathology  of,  314 
prognosis  of.  315 
symptoms  of,  314 
treatment  of,  315 
Periosteal  cachexia,  375 
Peritoneum,  diseases  of,  244 
tuberculosis  of,  252 
diagnosis  of,  253 
pathology  of,  252 
prognosis  of,  253 
symptoms  of,  253 
treatment  of,  254 

Pernicious  anemia,  progressive,  345 
blood  changes  in,  346 
causes  of,  345 
diagnosis  of,  348 


INDEX. 


8si 


Pernicious  anemia,    progressive,    morbid 

anatomy  of,  345 
prognosis  in,  348 
symptoms  of,  347 
treatment  of,  348 

Persistence  of  ductus  arteriosus,  396 
of  omphalomesenteric  duct,  85 

Pertussis,  713 

Petit  mal,  523 

Pharyngeal  catarrh,  treatment  of,  458 

Pharyngitis,  acute,  430 

Phenyl-hydrazin  test  in  diabetes  mellitus, 

387 
Phimosis,  319 

symptoms  of,  319 
treatment  of,  319 
Phlebitis,  rheumatic,  363 
Phobias,  540 

Physical  development,  general  considera- 
tions on,  792 

signs  other  than  murmurs  in  diagnosis 
of  valvular  diseases  of  heart,  im- 
portance of,  394 
Physiologic  albuminuria,  300 

glycosuria,  286 

Physiology  of  development  of  teeth,  168 
of  heart,  391 
of  infant  and  child,  17 
of  micturition,  292 
Pigeon-breast,  28 
"  Pinctosis,"  347 
Pin-worms,  254 
Pityriasis  rosea,  770 
Plague,  bubonic,  738 

causes  of,  739 
diagnosis  of,  740 
symptoms  of,  739 
treatment  of,  740 
types  of,  739 
Plastic  meningitis,  572 
Plethora,  330 
Pleurisy,  483 

causes  of,  483 
diagnosis  of,  487 
interlobar,  489 
causes  of,  489 
diagnosis  of,  490 
physical  signs  of,  489 
pathology  of,  484 
physical  signs  of,  486 
prognosis  of,  486 
symptoms  of,  485 
treatment  of,  488 
Pleuritis,  purulent,  492 
Pleuropneumonia,  490 
diagnosis  of,  491 
prognosis  of,  491 
Pleurothotonos  in  pericarditis,  404 
Pneumonia,  croupous,  471 
bacillus  of,  472 


Pneumonia,  croupous,  causes  of,  472 
chill  in,  473 
complications  of,  475 
diagnosis  of,  475 

from  meningitis,  475 
gangrene  of  lung  in,  treatment 

of,  482 
hernia  of  lung  in,  treatment  of, 

482 
pathology  of,  472 

stage   of  engorgement   in, 

472 
of    gray   hepatization 

in,  473 
of  red  hepatization  in, 

472 

of  resolution  in,  473 
physical  signs  of,  474 
prognosis  of,  475 
pulmonary  edema  in,  treatment 

of,  482 

symptoms  of,  473 
treatment  of,  476 
bathing  in,  476 
clothing  in,  478 
cold  applications  in.  477 

pack  in,  477 
counterirri tants  in,  479 
food  in,  478 
hot  bath  in,  476,  477 
hygiene  in,  476 
ice  poultice  in,  477 
medicines  in,  480 
poultices  in,  479 
stimulants  in,  478 
hypostatic,  491 
inspiration,  77 
the  blood  in,  353 
Pneumopericardium,  407 
Poikilocytosis,  332 
Poliomyelitis  anterior  acuta,  589 
Polyadenitis,  malignant,  738 
Polychromatophilia,  332 
Polyneuritis,  561 
Polypi,  mucous,  of  nose,  429 
rectal,  238 
umbilical,  84 
Polyuria,  286 

causes  of,  286 
diagnosis  of,  286 
Posterior  fontanel,  36 

closure  of,  36 

Postparalytic  chorea,  531,  537 
Posture  of  child  in  health  and  disease, 

42 
Potassium  iodid,   effect  of,  on  mother's 

milk,  118 
Pott's  disease,  826 

Poultices  in  croupous  pneumonia,  479 
Predigestion  of  milk,  142 


852 


INDEX. 


Prepuce,  adherent,  319 

treatment  of,  319 
Pressure  palsy  in  rachitis,  368 
Prickly  heat,  767 
Primary  anemia,  simple,  339 

anemias,  335 
Proctitis,  241 

catarrhal,  241 

causes  of,  242 

diphtheric,  242 

enemata  in,  243 

membranous,  242 

symptoms  of,  242 

treatment  of,  243 

ulcerative,  242 

Progressive  muscular  atrophies,  602 
Prolapse  of  anus,  239 

of  rectum,  237 
Proprietary  foods,  149 

intended   to   be    used    without 

milk,  150 

Prostatic  gland  in  children,  30 
Proteids  in  milk,  109 

estimation  of,  118 
Pseudohypertrophic    muscular   paralysis, 

603 
Pseudoleukemia,  349 

splenic,  340 

Pseudoleukocythemia  infantum,  345 
Pseudomembranous  laryngitis,  445 
Psoriasis,  770 

prognosis  of,  771 

treatment  of,  771 
Psychic  tic,  53° 
Psychoses,  transitory,  538 
Ptyalism,  164 

causes  of,  164 

symptoms  of,  165 

treatment  of,  165 
Pulmonary  artery,  atresia  of,  396 
stenosis  of,  396 

collapse,  491 

emphysema,  462 

treatment  of,  463 

gangrene,  49*1 

tuberculosis,  chronic,  612 
Pulse,  Corrigan,  415 

water-hammer,  415 
Pulse-rate  in  infants  and  children,  25 

normal,  392 
Pulsus  celer,  413 

Purgatives  in  congestion  of  liver,  271 
Purpura,  771 

hsemorrhagica,  772 
treatment  of,  773 

rheumatica,  772 

prognosis  of,  772 
treatment  of,  772 

simplex,  771 
Purpuric  fever,  malignant,  706 


Purulent  meningitis,  570,  572 

rhinitis,  428 
Pyelitis,  315 

causes  of,  315 

diagnosis  of,  316 

pathology  of,  316 

symptoms  of,  316 

treatment  of,  316 

Pyloric  hypertrophy  with  stenosis,  184 
symptoms  of,  184 
treatment  of,  185 
Pyuria,  289 

Q- 

QUARTAN  type  of  malarial  fever,  691 
Quinin  eruption,  746 

rectal  injections  of,  in  ileocolitis,  217 
Quotidian  type  of  malarial  fever,  691 

R. 

RACHITIC  asthma,  448 

"rosary,"  369 
Rachitis,  364 

causes  of,  365 
craniotabes  in,  367 
deformities  in,  368 
diet  in,  373 
hygiene  in,  372 
medicinal  treatment  of,  374 
pathology  of,  371 
pressure  palsy  in,  368 
preventive  treatment  of,  372 
prognosis  of,  372 
symptoms  of,  general,  366 
treatment  of,  372 
Ranula,  167 

treatment  of,  167 
Rash  in  scarlet  fever,  669 
Raynaud's  disease,  557 
causes  of,  558 
prognosis  of,  558 
symptoms  of,  558 
treatment  of,  558 
Reaction  of  milk,  no 
Rectal  injection  in  intussusception,  234 

polypi,  238 

Rectum,  diseases  of,  237 
inflammation  of,  241 
prolapse  of,  237 

actual  cautery  in,  238 
causes  of,  237 

cold-water  injections  in,  238 
operation  in.  238 
symptoms  of,  238 
treatment  of,  238 
"  Red  gum,"  768 

hepatization,  stage  of,  in  croupous 
pneumonia,  472 


INDEX. 


853 


Reflex  action,  diminution  of,  503 

cerebral,  503 
excess  of,  502 

cerebral,  502 
spinal,  503 
Reflexes,  concept,  501 

in  infantile  spinal  paralysis,  593 

modification  of,  502 

muscle,  501 

significance  of,  502 

skin,  501 

somatic,  501 

their   physiology    and    significance, 

500 
Regurgitation,  aortic,  415 

mitral,  413 
Renal  calculi,  316 

symptoms  of,  317 
catarrh,  acute,  301 
hyperemia,  301 
Respiration,  artificial,  Laborde's  method 

of,  50 

Schultze's  method  of,  50 
Sylvester's  method  of,  50 
rate  of,  in  infants  and  children,  26 
type  of,  in  infants  and  children,  26 
Respiratory  organs,  422 

upper,  diseases    of,  causes  of, 

422 

pathology  of,  422 
Rest  in  endocarditis,  418 
Retropharyngeal  abscess,  431 
causes  of,  431 
diagnosis  of,  432 
from  caries  of  cervical  vertebrae, 

433 

prognosis  of,  432 

symptoms  of,  432 

treatment  of,  432 
lymphadenitis,  431 
Rheumatic  fever,  355 

causes  of,  355 

cold  applications  in,  360 

complications  in,  357 

course  of,  359 

diagnosis  of,  358 

diet  in,  362 

duration  of,  359 

endocarditis  in,  357 

morbid  anatomy  of,  356 

pericarditis  in,  357 

preventive  treatment  of,  362 

prognosis  of,  359 

salicylates  in,  360,  361 

symptoms  of,  356 

treatment  of,  360 

urine  in,  356 

pharyngitis,  431 
phlebitis,  363 
Rheumatism,  acute,  355 


Rheumatism,  acute  articular,  355 

chronic,  363 

inflammatory,  355 

muscular,  362 
Rhinitis,  acute,  426 

treatment  of,  426 

atrophic,  428 

chronic,  427 

hypertrophic,  427 
simple,  427 

croupous,  429 

membranous,  429 

purulent,  428 

syphilitic,  429 
Rhythmic    movements,    automatic,   517, 

519 

"Rice-water"  discharges,  35 
Rickets,  364 
Ringworm  of  body,  777 

of  scalp,  775 

Risus  sardonicus  in  tetanus,  77 
Romberg's  symptom  in  hereditary  ataxia, 

601 
Roseola,  761 

vaccinia,  761 
Rotch's  method  of  home  modification  of 

milk,   134 

milk   formulas   for    infants    prema- 
turely born,  58 
Rotheln,  735 
Round  worms,  256 

diagnosis  of,  258 
symptoms  of,  257 
treatment  of,  258 
Rubella,  735 

causes  of,  735 
diagnosis  of,  737 

from  measles,  737 
from  scarlet  fever,  737 
from  varicella,  737 
from  variola,  737 
eruption  in,  736 
incubation  in,  736 
prognosis  of,  736 
symptoms  of,  736 
treatment  of,  737 
Rubeola,  729 

S. 

SALAAM  convulsions,  517,  520 
Salicylates  in  rheumatic  fever,  360,  361 
Saline  cathartics,  effect  of,  on  mother's 

milk,  118 
Salines  in  appendicitis,  250 

in  cirrhosis  of  liver,  277 
Salivary  glands  in  infancy,  40 
Salts,  inorganic,  in  milk,  IIO 

of  milk,  estimation  of,  117 
Sarcoma  of  kidney,  318 


854 


INDEX. 


Scabies,  773 

diagnosis  of,  773 
treatment  of,  773 
Scalp,  ringworm  of,  775 
Scarlatina,  666 

surgical,  672 
Scarlet  fever,  666 

adenitis  in,  668 
causes  of,  666 
Class-Gradwohl  diplococcus  of, 

666 

complications  of,  674 
ear,  675 
heart,  676 
nervous,  676 
desquamation  in,  670 

"  collarette  "  in,  670 
diagnosis  of,  673 
diet  in,  678 
ear  complications  in,  675 

treatment  of,  675 
fulminating  type  of,  672 
hygiene  in,  677 
preventive  treatment  of,  677 
prognosis  of,  677 
rash  in,  669 

duration  of,  670 
relapses  in,  676 
"  strawberry  tongue"  in,  669 
symptoms  of,  668 
treatment  of,  677 
types  of,  671 

McCollom's,  672 
urine  in,  669 

albumin  in,  673 
Schultze's  method  of  treating   asphyxia 

neonatorum,  50 
Sclerema,  78 

causes  of,  78 
definition  of,  78 
diagnosis  of,  79 
pathology  of,  78 
prognosis  of,  79 
symptoms  of,  78 
treatment  of,  79 
Sclerosis,  disseminated,  599 
causes  of,  599 
medicinal  treatment  of,  601 
pathology  of,  600 
prognosis  of,  600 
symptoms  of,  599 

"scanning    speech"      in, 

599 

treatment  of,  600 
of  kidney,  309 
of  liver,  274 
Scorbutus,  375 

causes  of,  375 
diagnosis  of,  378 

differential,  378 


Scorbutus,  diet  in,  379 
duration  of,  378 
heart  and  circulatory  apparatus  in, 

377 

kidneys  in,  377 

pathology  of,  375 

prognosis  of,  378 

symptoms  of,  376 

"  therapeutic  test"  of,  379 

treatment  of,  379 
Scrofulous  liver,  279 
Scurvy,  infantile,  375 

land,  772 

Sebaceous  glands  in  infancy,  41 
Seborrhea,  774 
Secondary  anemia,  350 
Sense  organs,  development  of,  795 
Septic   infection,   diseases  produced  by, 

74 
general,  of  new-born,  74 

preventive     treatment 

of,  75 

symptoms  of,  74 
treatment  of,  75 

interstitial  nephritis,  acute,  303 
Serum-test  for  typhoid  infection,  625 
Sharpless'  table  on  condition  of  blood  in 

differentiation  of  diseases,  354 
Shingles,  764 
Shock,  823 

injuries  and,  822 
Sick  headache,  559 
Sight  in  infancy,  39 
Sigmoid  flexure  in  children,  34 
Significance  of  reflexes,  502 
Simple  atrophy,  379 

cerebral  meningitis,  570 

chronic  rhinitis,  427 

diarrhea,  193 
Size  of  infant  at  birth,  17 
Skin,  development  of,  797 

diseases  of,  743 

inflammation  of,  743 

reflexes,  501 
Sleep  in  infancy,  90 
Small  intestine,  32 

length  of,  in  infant,  32 
Smallpox.     See  Variola,  680 

hemorrhagic,  682 
Snuffles,  424 

Sodium  chlorid  injections  in  acute  gastri- 
tis, 178 
Solids,   percentage  of,    in   human  milk, 

"3 

Somatic  reflexes,  501 
Somnaic  epilepsy,  524 
Soor,  159 

Spasm  of  glottis,  448 
Spasmodic  asthma,  458 
croup,  440 


INDEX. 


855 


Spasms,  habit,  536 
in  tetany,  513 
Specific  infectious  diseases,  605 

parotitis,  711 
Speech,  disorders  of,  437 
Spermatic  cord,  torsion  of,  325 
Spinal  excess  of  reflex  action,  503 

paralysis,  infantile,  589 
Spleen,  position  of,  in  children,  28 
Splenic  anemia,  340 

pseudoleukemia,  340 
Spondylitis,  826 

Sponge-baths  in  chronic  gastritis,  182 
Spotted  fever,  706 
Sprue,  159 

Spurious  cephalhematoma,  63 
Stenosis,  mitral,  414 
of  aorta,  396 
of  intestine,  192 
of  pulmonary  artery,  396 
Sterilization  of  milk,  123 
Sternocleidomastoid,  hematoma  of,  67 

symptoms  of,  68 
Stigmata  in  hysteria,  550 
Stimulants  in  croupous  pneumonia,  478 
Stokvis'  test  for  indicanuria,  287 
precaution  in,  288 
Stomach,  31 

capacity  of,  at  birth,  31 
dilatation  of,  191 

diagnosis  of,  191 
irrigation  in,  192 
pathology  of,  191 
symptoms  of,  191 
treatment  of,  192 
diseases  of,  1 74 
in  infancy,  31 
inflammation  of,  acute,  174 

chronic,  178 

position  of,  in  infants,  31 
ulcer  of,  in  children,  185 
fc  blisters  in,  189 
causes  of,  186 
diet  in,  189 
irrigation  in,  189 
nutrient  enema  in,  189 
symptoms  of,  1 87 
treatment  of,  1 88 
Stomatitis,  156 

aphthous,  157 

causes  of,  157 

cleansing  solutions  in,  157,  158 
laxatives  in,  157 
treatment  of,  157 
croupous,  163 
diphtheric,  163 

treatment  of,  164 
follicular,  157 
gangrenous,  161 
causes  of,  161 


Stomatitis,  gangrenous,  cauterants  in,  163 
pathology  of,  161 
symptoms  of,  161 
treatment  of,  163 
mercurial,  164 
mycosa,  159 

causes  of,  159 
curative  treatment  of,  160 
oidium  albicans  as  cause  of,  159 
prophylactic  treatment  of,  160 
symptoms  of,  160 
treatment  of,  160 
parasitic,  159 
simple  catarrhal,  156 

causes  of,  156 
symptoms  of,  156 
treatment  of,  156 
syphilitic,  164 
ulcerative,  158 
causes  of,  158 
hygiene  in,  159 
symptoms  of,  158 
treatment  of,  159 
varieties  of,  156 
vesicular,  157 
Stone  in  bladder,  295 
causes  of,  295 
diagnosis  of,  297 
symptoms  of,  296 
treatment  of,  298 
Stramonium  bromid  in  ulcer  of  stomach 

in  children,  189 
Strangulation  of  intestine,  230 
"Strawberry  tongue"  of  scarlet  fevei, 

669 

Strophulus,  768 
St.  Vitus'  dance,  528 
Subacute  milk  infection,  206 
Subaponeurotic  cephalhematoma,  63 
Sudamina,  767 
Suffocative  catarrh,  467 
Sugar  in  milk,  109 
Summer  complaint,  206 

diarrhea,  206 
Supplementary  head,  63 
Suppurative  inflammation  of  liver,  273 

myocarditis,  acute,  410 
Surgical  scarlatina,  672 
Swamp  fever,  689 
Sweat-glands  in  infancy,  40 
Sydenham's  chorea,  528 
Sylvester's  method  of  treating  asphyxia 

neonatorum,  50 
Symmetric  gangrene,  557 
Symptomatology,  general,  and  diagnosis 

of  disease  in  children,  41 
Synovitis,  824 
Syphilis,  718 

bone-lesions  in,  723 
diagnosis  of,  "J22 


856 


INDEX. 


Syphilis,  diagnosis  of,  from  rachitic  bone- 
lesions,  724 

from  scrofulous  lesions  of  skin, 
722 

early  manifestations  of,  719 

internal  medication  in,  727 

inunctions  in,  726 

late  manifestations  of,  724 

prognosis  of,  724 

symptoms  of,  719 

treatment  of,  726 
Syphilitic  dactylitis,  724 

inflammation  of  liver,  273 

rhinitis,  429 

stomatitis,  164 

teeth,  725 

T. 

TABLE  of  causes  of  infantile  convulsions, 

5.11 
of  increase  in  weight  of  children,  18 

Sharpless' ,  on  condition  of  blood  in 

differentiation  of  diseases,  354 
Tache  cerebrate  in  simple  cerebral  men- 
ingitis, 572 
Tachycardia,  398 

in  goiter,  555 

Tachypnea  in  hysteria,  55 l 
Tsenia  mediocanellata,  259 

solium,  259 
Tapeworm,  259 

treatment  of,  262 
Tapping  of  ventricles  in  hydrocephalus, 

554 
Teeth,  milk-,  168,  169 

physiology  of  development  of,  168 

syphilitic,  725 
Temperature  in  appendicitis,  247 

in  infants  prematurely  born,  54 

normal,  variations  of,  in  infants,  21 

of  infant  at  birth,  21 
Tenia,  259 

development  of,  history  of,  260 

diagnosis  of,  259 

infection  by,  mode  of,  260 

symptoms  of.  262 

treatment  of,  262 

Tertian  type  of  malarial  fever,  691 
Testicle,  inflammation  of,  322 

tubercular  disease  of,  322 
treatment  of,  523 

undescended,  325 

treatment  of,  325 
Testicles,  the,  in  infancy,  41 
Tetanus,  567 

bacillus  of  Nicolaierin,  567 

causes  of,  567 

diagnosis  of,  569 

in  new-born,  76 


Tetanus  in  new-born,  cause  of,  76 
ice  to  spine  in,  77 
prophylactic  treatment  of,  77 
symptoms  of,  77 
warms  baths  in,  77 
pathology  of,  569 
prognosis  of,  569 
symptoms  of,  568 
treatment  of,  569 
Tetany,  511 

"  accoucher's  hand  "  in,  513 
causes  of,  512 
Chvostek's  sign  in,  514 
diagnosis  of,  515 
Erb's  sign  in,  514 
etiology  of,  512 
latent,  514 

pathologic  anatomy  of,  515 
prognosis  of,  516 
spasms  in,  513 
symptoms  of,  513 
treatment  of,  516 
Trousseau's  sign  of,  514 
Thorax,  size  of,  in  children,  27 

table  of  proportionate  sizes  of  head 

and,  38 

Threadworms,  254 
Thrombus  neonatorum,  64 
Thrush,  159 

Thymus  gland,   physiology   of,  in  chil- 
dren, 27 
Tic,  535 

convulsif,  517 
convulsive,  536 
psychic,  536 
simple,  536 
treatment  of,  536 
Tics,  complex  coordinated,  536 
Tinea  circinata,  777 

treatment  of,  778 
favosa,  778 

microscopic  examination  in,  779 
treatment  of,  779 
kerion,  776 

prognosis  of,  777 
treatment  of,  776 
tonsurans,  microscopic  examination 

in,  776 

trichophytina,  775 
diagnosis  of,  775 
etiology  of,  775 
•symptoms  of,  776 
tonsurans,  775 

Toluol  solution  in  diphtheria,  643 
Tongue,  165 

diseases  of  the,  165 
Tongue-tie,  439 

Tonics  in  subacute  milk  infection,  211 
Tonsillitis,  433 
acute,  433 


INDEX. 


857 


Tonsillitis,  acute,  causes  of,  434 
prognosis  of,  435 
sequelae  of,  436 
symptoms  of,  434 

of  lacunar  form  of,  434 
of   phlegmonous    form  of, 

434 

of  simple  form  of,  434 
treatment  of,  435 
chronic,  437 

Tonsils,  hypertrophy  of,  437 
Torsion  of  spermatic  cord,  325 
Tracheotomy  in  diphtheria,  656 
Traumatic  dermatitis,  743 
Tricuspid  disease,  physical  signs  of,  416 
Trismus,  77 

Trousseau's  sign  of  tetany,  514 
True  croup,  445 
Truss  in  inguinal  hernia,  237 

in  umbilical  hernia,  87 
Tube,  intubation,  method  of  introducing, 

660 

Tubercular  arthritis,  825 
disease  of  testicle,  322 
diseases  of  joints,  824 
meningitis,  575 
Tuberculosis,  605 
bacillus  of,  606 

mode  of  infection  by,  606 
causes  of,  606 
age  in,  606 
hereditary     predisposition     as, 

607 

susceptibility  in,  606 
general,  609 
of  kidney,  317 
of  lungs,  610 
of  peritoneum,  252 
pulmonary,  chronic,  612 
climate  in,  617 
diagnosis  of,  614 
drugs  in,  615 
physical  signs  of,  613 
preventive     treatment    of, 

614 

prognosis  of,  614 
symptoms  of,  612 
treatment  of,  614 
Tuberculous    bronchopneumonia,  acute, 

610 

Tubular  nephritis,  acute,  303 
Tumors,  nasal  fibrous,  430 

of  brain  and  its  meninges,  585 
causes  of,  585 
convulsions  in.  586 
diagnosis  of,  588 
headache  in,  586 
optic  neuritis  in,  586 
symptoms  of,  585 
treatment  of,  588 


Tumors  of  brain,  vomiting  in,  586 
of  kidney,  318 
ovarian,  in  children,  325 
Turpentine  eruption,  746 

stupe  in  croupous  pneumonia,  480 
Tympanites  in  intestinal  obstruction,  232 
Typhoid  fever,  619 

bacillus  of  Eberth  in,  619 

baths  in,  630 

causes  of,  619 

complications  of,  625 

diagnosis  of,  625 

Widal  test  in,  625 

diet  in,  628 

drugs  in,  630 

eruption  in,  624 

fever  in,  623 

morbid  anatomy  of,  621 

pathology  of,  621 

preventive  treatment  of,  627 

prognosis  of,  627 

relapses  in,  624 

sequelae  of.  625 

symptoms  of,  622 

treatment  of,  627 
infection,  serum  test  for,  625 


U. 

ULCER  of  stomach  in  children,  185 
blisters  in,  189 
causes  of,  1 86 
diet  in,  189 
irrigation  in,  189 
nutrient  enema  in,  189 
symptoms  of,  187 
treatment  of,  1 88 
Ulcerative  proctitis,  242 
stomatitis,  158 

causes  of,  158 
hygiene  in,  159 
symptoms  of,  158 
treatment  of,  159 
Umbilical  hemorrhage,  69 
causes  of,  69 
ligation  in,  69 
prognosis  of,  69 
prophylaxis  of,  69 
treatment  of,  69         « 
hernia,  86 

rubber  adhesive  strips  in,  87 
treatment  of,  87 
truss  in,  87 
polypi,  84 

Umbilicus,  inflammation  of,  76 
Undescended  testicle,  325 
Uric  acid,  389 

conditions,  389 

treatment  of,  390 


858 


INDEX. 


Urine,  284 

diacetic  acid  in,  288 

hemoglobin  in,  291 

in  acute  Bright' s  disease,  306 

in  diabetes  mellitus,  386 

in  scarlet  fever,  669 

incontinence  of,  291 

quantity  of,  secreted  in  children,  284 
in  infancy,  30 

red  blood-corpuscles  in,  289 
Urticaria,  779 

V. 

VACCINATION,  age   to  perform   first,  in 

child,  687 
in  smallpox,  685 
in  whooping-cough,  718 
Vaccine  crust,  687 

inoculation,  arm-to-arm,  686 
lymph,  glycerinized,  686 
points,  ivory,  686 
Vaccinia,  685 

history  of,  685 

technic  of  inoculation  with,  686 
Valvulitis,  410 
Varicella,  687 

causes  of,  687 
diagnosis  of,  688 

from  variola,  689 

from  varioloid,  688 
eruption  in,  688 
prognosis  of,  689 
symptoms  of,  688 
treatment  of,  689 
Varicocele,  325 
Variola,  680 

causes  of,  680 
complications  in,  683 

circulatory,  683 

dermal,  683 

digestive,  683 

nephritic,  683 

ocular,  683 

respiratory,  683 
diagnosis  of,  684 

from  varicella,  684 
eruption  in,  681 

confluent  form  of.  682 

discrete  form  of,  68 1 
hsemorrhagica,  682 
incubation  period  in,  68l 
pathology  of,  683 

papule  in,  683 

pustules  in,  683 
prognosis  of,  684 
stage  of  invasion  of,  68 1 
symptoms  of,  68 1 
treatment  of,  685 
vaccination  in,  685 


Varioloid,  682 

Venesection   in   acute  diffuse    nephritis, 

308 

Ventricular  septum,  defect  of,  396 
Vermiform     appendix,    position     of,    in 

children,  34 
Vesicular  stomatitis,  157 
Virus,  varieties  of,  686 
Visual  disturbances  in  migraine,  560 
Volvulus,  230,  235 

Wahl's  sign  of,  235 
Vomiting,  chronic,  178 
cyclic,  183 

causes  of,  183 
diagnosis  of,  184 
diet  in,  184 
treatment  of,  184 
in  brain-tumor,  586 
in  intestinal  obstruction,  232 
in  whooping-cough,  718 
Von  Graefe's  symptom  of  exophthalmic 

goiter,  556 

Vulvitis,  aphthous,  in  children,  743 
Vulvovaginitis,  321 
gonorrheal,  321 
prognosis  of,  321 
symptoms  of,  321 
treatment  of,  322 


W. 

WAHL'S  sign  of  volvulus,  235 
Wangenbrand,  161 
Warm  baths  in  multiple  neuritis,  564 
in  tetanus  in  new-born,  77 
Wasting,  simple,  379 
Water-hammer  pulse,  415 
Waxy  kidney,  309 

liver,  279 
Weaning,  100 

gradual  method  of,  101 
Weight,  increase  of,  in  children,  17 

of  brain  at  birth,  39 

of  heart  at  birth,  25 

of  infant  at  birth,  17 

proportion    of,   to    length    in    infant 
and  child,  18 

table  of  increase  in,  18 
Westcott's  method  of  home  modification 

of  milk,  137 

Wet-nurse,  feeding  by,  104 
White  blood,  340 

swelling,  825 
Whooping-cough,  713 

complications  in,  715 

diagnosis  of.  716 

incubation  period  in,  713 

intubation  in,  718 

pathology  of,  Ji6 


INDEX. 


859 


Whooping-cough,  sequelae  in,  715 

symptoms  of,  714 

treatment  of,  716 
local,  717 
systemic,  717 

vaccination  in,  718 

vomiting  in,  treatment  of,  718 

"  whoop"  in,  714 
\Vidal  test  for  typhoid  fever,  625 
Winckel's  disease,  72 
"  Witch's  milk,"  80 
Wormian  bones,  37 
Worms,  pin-,  254 


Worms,  round-,  256 

tape-,  259 

thread-,  254 
Wrist-drop  in  multiple  neuritis,  563 


Y. 


YELLOW  groom,  70 


ZONA,  764 


Z. 


Date  Due 


CAT.   NO.   23   233  PRINTED   IN    U.S.A. 


1901 
Taylor,  John  Madison. 

Manual  of  the  diseases  of 
children. 


WS200 


1901 
Taylor.  John  Madison. 

Manual  of  the  diseases  of  children, 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


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